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SocietyofSkeletalRadiology 38thAnnualMeeting March8–11,2015 JWMarriottCamelbackInn Resort&Spa Scottsdale,AZ Table of Contents WelcomefromtheProgramChair..........................................................................................................................................3 2014–2015Committees..........................................................................................................................................................4 Accreditation...........................................................................................................................................................................6 SSRPaperAwardWinners......................................................................................................................................................8 YoungInvestigatorAwardWinners........................................................................................................................................9 ThankYoutoOur2015Exhibitors........................................................................................................................................11 SSRPastPresidents...............................................................................................................................................................11 UltrasoundWorkshopInstructors.........................................................................................................................................12 Research,EducationandDevelopment(RED)FundandPatrickLiuAwardContributors....................................................13 ProgramScheduleOverview.................................................................................................................................................14 IndustrySponsoredLunch....................................................................................................................................................15 SundaySchedule...................................................................................................................................................................17 MondaySchedule..................................................................................................................................................................33 TuesdaySchedule..................................................................................................................................................................55 WednesdaySchedule............................................................................................................................................................73 FocusSession/SAMsSlides...................................................................................................................................................95 ePosters..............................................................................................................................................................................165 2 Welcome SocietyofSkeletalRadiology th 38 AnnualMeeting March8–11,2015 JWMarriottCamelbackInn Resort&Spa Scottsdale,AZ Welcometothe38thAnnualSSRScientificMeetingattheJWMarriottCamelbackResortinScottsdale,Arizona! FromourearlybeginningsastheSoutheasternSkeletalRadiologySociety,wehavegrowntoanorganizationwithover 1,200membersnowknownastheSSR. Thismeetingispossibleonlythoughthetirelesseffortsofourcommitteechairs,theexecutivecommittee,andour managementteamatVeritasMeetingSolutions.Althoughthemeetingisthevisiblerewardofthatwork,activitiesof thesocietyleadershipoccuryearround;theseactivitieswillbecomemoreandmoreevident,bringingvaluetoSSR membershipthroughouttheyear. AspecialthankyougoestoJonathanLuchs,ZehavaRosenberg,andHilaryUmansforcoordinatingthisyear’sSAMs. ThanksalsotoYoavMoragforcoordinatingtheUltrasoundHandsOnSession(thisyearfocusingontheelbow)andCat RobertsforcoordinatingtheCaseoftheDay. Thisyear,arecordbreaking135abstractsweresubmittedfor52podiumslots.Byvaryingthepresentationtimesfor abstractsslightly,thenumberofpodiumslotshasbeenincreasedthisyearby16%comparedtopreviousyears. SubmissionofePostersincreasedsubstantiallythisyearaswell,providingparticipantswithadditionallearning opportunities.Asbefore,ePostershavebeenarrangedintogroupscorrespondingtothetopicsinthescientificsessions. WehavealsoseenapplicationsforourYoungInvestigatorAwardsincreasesteadily,numbering19thisyear,attestingto thevigorousinvolvementofournewestmembers. Manyofyouwillnodoubtrecallwithfondnessourlastmeetingatthisfacilityin2010,whichwasuniversallyacclaimed asnotonlyoneofthebestvenuestheSSRhaschosen,butalsoalifechangingexperienceforseveralmemberswho havesubsequentlyleftradiologyandbecomecowboyartists.Forthosestillsloggingawayinthereadingroomtrenches, ourMondaynightgalapromisesthrills,chills,andspills(ofBBQsauce),includinganencoreperformancebyourownIT Band! Theprogramcommitteeinvitesyoutorelaxandenjoywhatwillundoubtedlybeourbestmeetingever! Warmly, AndySonin,MD 2015ProgramCommitteeChair 3 2014–2015 Committees EXECUTIVECOMMITTEE President WilliamMorrison,MD PresidentElect AndrewSonin,MD Secretary LauraBancroft,MD Treasurer LawrenceWhite,MD PastPresident KennethBuckwalter,MD AuditCommittee DevonAKlein,MD,MPH(CommitteeChair) DavidGlennDisler,MD ThomasLeePopeJr.,MD,FACR ElectronicCommunicationsCommittee JeffreyM.Brody,MD(CommitteeChair) PeterLouisGlickman,MD PerryJ.Horwich,MD MatthewCarlLarrison,MD JonellePetscavageThomas,MD,MPH DanielMWalz,MD FinanceCommittee LawrenceM.White,MD(CommitteeChair) EricA.Brandser,MD KennethLee,MD HistoricalCommittee BarbaraNancyWeissman,MD(CommitteeChair) W.BonnerGuilford,MD,FACR CharlesS.Resnik,MD MembershipCommittee TroyFarrStorey,MD(CommitteeChair) KathleenCaseFinzel,MD ElaineSusanGould,MD,FACR JohnM.Payan,MD;Decatur,GA ScottE.Preusen,MD;Wilmette,IL HilaryR.Umans,MD;Ardsley,NY NominatingCommittee DavidA.Rubin,MD(CommitteeChair) DonnaG.Blankenbaker,MD(ChairofRulesCommittee) WilliamBrianMorrison,MD(President) 4 PracticeGuidelinesandTechnicalStandardsCommittee JonathanS.Luchs,MD(CommitteeChair) DawnHastreiter,MD,PhD MaryGabriellaHochman,MD,MBA AnnamalaiMuthiah,MD BarbaraNancyWeissman,MD AdamC.Zoga,MD ProgramCommittee AndrewSonin,MD,FACR(CommitteeChair) LauraW.Bancroft,MD DouglasRobertson,MD,PhD LawrenceWhite,MD ResearchCommittee JennyTeresaBencardino,MD(CommitteeChair) JosephBurns,MD,PhD LauraMarieFayad,MD AliceHa,MD,MS HakanIlaslan,MD KenL.Schreibman,MD,PhD ResidencyandFellowshipEducationCommittee CorrieM.Yablon,MD(CommitteeChair) StephanieBernard,MD BethanyU.Casagranda,DO JosephG.Craig,MBChB TheodoreT.Miller,MD BrianDavidPetersen,MD HumbertoRosas,MD JasonWoodsStephenson,MD DanielMWalz,MD RulesCommittee DonnaG.Blankenbaker,MD(CommitteeChair) SayedAli,MD FrancescaBeaman,MD EricBrianCallaghan,MD MichaelG.Fox,MD WendyE.McCurdy,MD SocioeconomicAffairsCommittee ChristopherJ.Hanrahan,MD,PhD(CommitteeChair) EdgarColon,MD PaulP.Harkey,MD JohnPan,MD,MPH,MBA DavidW.Tsai,MD SailajaYadavalli,MD,PhD ExecutiveOffice VeritasMeetingSolutions 2575NorthwestParkway Elgin,IL Email:[email protected] Phone:8477526249 5 Accreditation SponsoredforContinuingMedicalEducationcreditbyRushUniversityMedicalCenter Learningobjectives Attheconclusionofthisactivity,thelearnerwillbeableto: 1. Applyreallifesituationstoclinicalpractice; 2. Integrateknowledgeandperformanceintheassessmentanddiagnosisofmusculoskeletalsportsinjury,tumors, traumaanddegenerativedisease; 3. IdentifytheanatomyofnormalMSKtissues,variantsandmimickerofdisease; 4. Identifymorphologic,histologicandimagingcharacteristicsofMSKdisease; 5. Describethespecificpathologythataccountsfortheappearanceofosseousandsofttissuesinthesettingof trauma,overuse,degeneration,inflammatory/autoimmuneandneoplasticconditionsonvariousimaging modalities; 6. Recognizetherelationshipofspecificbiomechanicalactivities,injuriesandtreatmentstotheappearanceof joints,bone,andsofttissuesonimagine,arthroscopic,andpathologicassessment; 7. Reviewtheoptimalroleofimaging,surgeryandhistopathologyinthediagnosisandmanagementof musculoskeletaldiseaseandhealth; 8. Identifythecomplementaryroleofemergingimagingtechniques,modalities,andinterventional/therapeutic proceduresinthediagnosisandmanagementofspecificmusculoskeletalconditions; 9. IllustratecompetencyinUltrasound,MRI,andtherapeuticapproachesintheassessmentandmanagementof themusculoskeletalsystem. Toobtaincredityoumustbepresentforthesession,completetheprogramevaluation,andreturnittostaff. Certificatesofparticipationwillbesentbyemail710daysaftertheclosingoftheSocietyofSkeletalRadiology AnnualMeeting. RushUniversityMedicalCenterisaccreditedbytheAccreditationCouncilforContinuingMedicalEducationtoprovide continuingmedicaleducationforphysicians.RushUniversityMedicalCenterdesignatesthisliveactivityforamaximum of19.4AMAPRACategory1Credit(s)TMPhysiciansshouldclaimonlycreditcommensuratewiththeextentoftheir participationintheactivity. ItisthepolicyoftheRushUniversityMedicalCenterOfficeofInterprofessionalContinuingEducationtoensurethatits CEactivitiesareindependent,freeofcommercialbiasandbeyondthecontrolofpersonsororganizationswithan economicinterestininfluencingthecontentofCE.Everyonewhoisinapositiontocontrolthecontentofan educationalactivitymustdiscloseallrelevantfinancialrelationshipswithanycommercialinterest(includingbutnot limitedtopharmaceuticalcompanies,biomedicaldevicemanufacturers,orothercorporationswhoseproductsor servicesarerelatedtothesubjectmatterofthepresentationtopic)withinthepreceding12months.Ifthereare relationshipsthatcreateaconflictofinterest,thesemustberesolvedbytheCECourseDirectorinconsultationwiththe OfficeofInterprofessionalContinuingEducationpriortotheparticipationofthefacultymemberinthedevelopmentor presentationofcoursecontent. SpecificPlannerandFacultydisclosurescanbefoundontheCMEhandoutinyourregistrationpacket. InaccordancewithrequirementsoftheFDA,theaudienceisadvisedthatinformationpresentedinthiscontinuing medicaleducationactivitymaycontainreferencestounlabeledorunapprovedusesofdrugsordevices.Pleasereferto theFDAapprovedpackageinsertforeachdrug/deviceforfullprescribing/utilizationinformation. 6 SelfAssessmentModule(SAM) Thismodule(oractivity)meetstheABR’scriteriaforaselfassessmentactivityintheABRMaintenanceofCertification program: FocusSession/SelfAssessmentModuleI:Foot&Ankle 1.5credits FocusSession/SelfAssessmentModuleII:Socioeconomic 1.5credits MusculoskeletalUltrasoundHandsOnWorkshop:Elbow Needs Achieving competence in elbowultrasound not only depends on knowledge of anatomy and pathology, but also familiarity with various techniques of acquiring ultrasound images including positioning, placement of the probe andmethodsforvisualizationofstructuresandavoidingartifact.Thesuccessofelbowultrasoundislargelydependent ontheskillsoftheindividualperformingtheultrasound.Oneofthemosteffectivelearningformatsisa handson workshopsupervisedbyexperiencedinstructors. Objectives Atthecompletionoftheultrasoundworkshop,theparticipantwillableto: x Explainandperformanelbowultrasoundexamination. 7 SSR Paper Award Winners 2014 MaryKristenJesse,MD “3DMorphologicAssessmentof NormalandAbnormalSiJointsand thePotentialImplicationsinthe DevelopmentofPainSyndrome” SelectedforpresentationatISS LawrenceWhite,MD “FemoroacetabularImpingement: AccuracyofNonArthrographic3T MRImaginginEvaluationofIntra ArticularPathologyoftheHip” SelectedforpresentationatRSNA 2013 LienSenchak,MD “ImagingofOsteoblastomaofthe AppendicularSkeletonwith PathologicCorrelation: SelectedforpresentationatISS MaryKristinJesse ”MorphologyofEndplateCement EstravasationCanPredictAdjacent LevelFractureinOsteoporotic PatiensUndergoingVertebroplasty andKyphoplasty”Selectedfor presentationatRSNA 2012 MeredithHayes,MD “PhosphaturicMesenchymalTumors ImagingFeaturesofaRareEntity WithClinicopathologicCorrelation” SelectedforpresentationatISS SrinivasanHarish,FRCPC “MRIoftheSpineandSacroiliac JointsforSpondyloarthropathy: InfluenceonClinicalDiagnostic ConfidenceandPatient Management” SelectedforpresentationatRSNA 2011 TalLaor,MD "JuvenileOsteochondritisDissecans (JOCD):IsItaGrowthDisturbanceof theSecondaryPhysisofthe Epiphysis?"Selectedforpresentation atISS DonnaBlankenbaker,MD “MRArthrographicAppearanceofthe PostOperativeAcetabularLabrum” SelectedforpresentationatRSNA 2010 MaximeFreire,MD “MREvaluationofRepairTissuein OsteochondralDefectsFollowing TreatmentwithAcellularScaffolds:High ResolutionMRHistologicalCorrelation inaGoatModel”Selectedfor presentationatISS PeterMacMahon,MD “InjectableCorticosteroidPreparations: AnEmbolicRiskAssessmentbyStaticand DynamicMicroscopicAnalysis”Selected forpresentationatRSNA 2009 ChristopherJ.Hanrahan,MD,PhD "TemporalEvolutionofMRIFindings afterRotatorCuffRepair"Selectedfor presentationatISS KevinJohnson,MD "ContrastEnhancedUltrasound CharacterizationoftheVascularityofthe RepairedRotatorCuff"Selectedfor presentationatRSNA 2008 StephanieA.Bernard,MD “CartilageCapThicknessMeasurement onT2WeightedMRImagingandthe RiskofSecondaryChondrosarcomain Osteochondromas” SelectedforpresentationatISS KelleyW.Marshall,MD “OsteochondralLesionsoftheLateral TrochleainthePediatricAthletewith ElbowPain” SelectedforpresentationatRSNA 2007 AdamZoga,MD “TheSportsHernia:WhatIsIt?HowDoI imageIt?WhatAreItsConfounders?” SelectedforpresentationatISS TalLaor,MD “TheEffectofChildhoodGrowthonthe AnteriorandPosteriorCruciate Ligaments” SelectedforpresentationatRSNA 2006 EricT.Chou,MD “BifurcatedDistalBicepsBrachiiTendon: MagneticResonanceImaging AppearancesandPrevalence” SelectedforpresentationatISS 8 LawrenceM.White,MD "DirectMRArthrographicAssessmentof RecurrentSymptomsPostShoulder InstabilityRepair:Correlationwith SecondLookSurgicalEvaluationsin40 Patients" SelectedforpresentationatRSNA 2005 StevenS.Gerguis,MD “ReviewoftheSecondarySignsof FemoracetabularImpingementand CorrelationwiththeHeadneckAngle MeasuredontheFrogLegLateralView” SelectedforpresentationatISS SuzanneE.Anderson,BMed “ComputerassistedSoftwarefor AccurateDeterminationofAcetabular CoveragewithConventional Radiography” 2004 MihraTaljanovic,MD,MS “BoneMarrowEdemainHip Osteoarthritis:QuantitativeAssessment withMRIandCorrelationwithClinical Exam,RadiographicFindingsand Histopathology” 2003 JosephR.DeMartini,MD “EffectsofMRGradientCoilInduced VibrationArtifactsandInherentPulse SequenceImperfectionsonPhase” 2002 DerekR.Armfield,MD “MRIofPosteriorMedialMeniscalRoot Avulsion” 2001 PatrickT.Liu,MD “ImprovedImagingofOsteoidOsteoma withDynamicGadoliniumEnhanced MRI” 2000 TimothyG.Sanders,MD “MRIatDifferentTimeIntervals Following HamstringHarvestforACL Reconstruction” PatrickT.LiuInnovationinResearchAwardRecipient SSRExcellenceAward 2014 GandikotaGirish,MD “PhotoacousticImagingofJoints” 2013 DouglasP.Beall,MD ”TissueDistributionofClondineFollowingIntraforminal ImplantationofBiodegradablepellets:PotentialAlternative toEpiduralSteroidforRadiculopathy” 2012 JoshuaM.Polster,MD “SingleEnergyPost–ProcessingTechniqueforBone MarrowImagingonCT” 2011 KennethLee,MD "TreatmentofChronicLateralEpicondylosisUsing HyperosmolarDextroseSolution:CanAcoustoelastography MonitorTissueHealing?" 2013 LukeScalcione,MD “HalluxValgus:SpectrumofImaging,SurgicalProcedures,and Complications” 2011 LuisBeltran,JasonMayo,JennyBencardino,Zehava Rosenberg,LuisNetoPecci,MariaDiazdeTuesta,OlgaRuiz “DiagnosticEvaluationofHipDysplasiaintheYoungAdult– EmphasisonCrossSectionalImaging” ACREducationAward–BestPoster 2014 DavidMelville,MD OsteoarthritisoftheBasalJointsoftheThumb:Imagingand Management Young Investigator Award Winners 2015 ShivaniAhlawat,MD TraumaticNeuromas:CommonMRIFeatures KimiaKKani,MD ConceptsofOperativeTreatmentinScapholunateInstability:AnImagingPerspective LaurenM.Ladd,MD QuantitativeandQualitativeComparisonof3.0tversus1.5tWarpImagingofHipProstheses DanielSiegal,MD SonographicEvaluationoftheDistalBicepsTendon:AccuracyandPitfallsintheDiagnosisofPartialThicknessTears AndrewWilmot,MD SubchondralInsufficiencyFractureoftheKnee:RevisingtheEpidemiologyandSoftTissueEdemaPattern 2014 LuisBeltran “Anatomy,DiagnosticPitfallsandVariantsoftheShoulderJointinAbductionandExternalRotationMRArthrography” ShadpourDemehri “AccuracyofConventionalandFunctionalMRIinDiagnosingIndeterminatePeripheralNerveSheath” AliceHa “DigitalTomosynthesistoDetectBoneHealing?:ComparisontoRadiographyandComputedTomography” KaushalMehta “SuperolateralHoffa’sFatPadEdemainCollegiateVolleyballPlayers” 9 2013 Gyftopoulos,Soterios,MD “CorrelationofMIRwithArthroscopyfortheDiagnosisofSubscapularisTendonTears” Raghavan,Meera,MD,BS “RadiomicsofSofttissueSarcomaComuterAidedImageAnalysisandCharacterizationofTumorHeterogeneity” RantioluAro,Michael,MD “AnatomicVariationsofFemoralNervesonHighResolution3TeslaMagneticResonanceNeurographyandTheirRelationto AbnormalNerveandMuscleImagingFindings” 2012 BethanyCasagranda,DO “CoronalObliqueImagingofTheKnee:CanItIncreaseRadiologists’ConfidenceinDiagnosingPosteriorRoot MeniscalTears?” GlennGaviola,MD “AssessmentofFellowshipTraineeClinicalCompetencyandGrowthwithanObjectiveStandardizedClinicalExaminationWithinthe MusculoskeletalFellowshipProgram:InitialExperience” JonellePetscavage,MD,MPH “Magnetic Resonance Imaging Findings of Adverse Reactions to Metallic Debris (ARMD) of MetalOnMetal Total Hip Replacements” NaveenSubhas,MD “MetalArtifactReductionUsingaMonoenergeticDualEnergyCTTechnique” 10 Thank You to Our 2015 Exhibitors Specialthankstothefollowingcompaniesfortheirsupportto theSocietyofSkeletalRadiologyin2015. Platinum BiomarinPharmaceuticals Silver AprioMedInc. Bronze AmericanCollegeofRadiology Elsevier ImageAnalysis LauraneMedicalLLC SiemensHealthcare SonoSiteFujiFilm SSR Past Presidents WilliamBonnerGuilford, MDJuly1978–June1980 TerryM.Hudson,MD July1996–June1998 JeremyJ.Kaye,MD July1980–June1982 WilliamF.Conway,MD,PhD July1998–June2000 CosmoL.Haun,MD July1982–June1984 ArthurA.DeSmet,MD July2000–June2002 WilliamW.Daniel, MDJuly1984–June 1986 B.J.Manaster,MD,PhD July2002–June2004 ArthurH.Newberg,MD July2004–June2006 AnneC.Brower,MD July1986–June1988 JenoI.Sebes,MDJuly 1988–June1990 CherylA.Petersilge,MD July2006–June2008 MarkJ.Kransdorf,MD July2008–March2010 MuraliSundaram,MD July1990–June1992 CarolL.Andrews,MD April2010–March2012 KennethBuckwalter,MD April2012–March2014 CharlesS.Resnik,MD July1992–June1994 WilliamBonnerGuilford, MDJuly1994–June1996 11 Ultrasound Workshop Instructors Organizer: YoavMorag,MDUniversityofMichiganMedical Center,AnnArbor,MI Instructors: MaryM.Chiavaras,MD,PhD–McMasterUniversity Ancaster,ON,CAN JosephG.Craig,MBChB–HenryFordHospital Detroit,MI GinaA.DiPrimio,MD–TheOttawaHospitalOttawa,ON, CAN GandikotaGirish,MD–UniversityofMichigan AnnArbor,MI KatrinaN.Glazebrook,MD–MayoClinicRochester,MN JonJacobson,MD–UniversityofMichigan AnnArbor,MI DavidM.Melville,MD–UniversityofArizonaMedicalCenterTucson,AZ TheodoreMiller,MD–HospitalforSpecialSurgery Mamaroneck,NY KambizMotamedi,MD–UCLA LosAngeles,CA AkiraM.Murakami,MD–BostonUniversitySchoolofMedicine Boston,MA Tito(Humberto)Rosas,MDUniversityofWisconsin Madison,WI MihraTalijanovic,MD–UniversityofArizona Tucson,AZ CorrieM.Yablon,MD–UniversityofMichiganMedicalCenter AnnArbor,MI Thank you to Sonosite FujiFilm for In Kind Support of Ultrasound Equipment Loaned for This Course 12 RED FUND and PATRICK T. LIU AWARD Donors SincereThankstoOur20142015Contributors LauraBancroft,MD LaurieLomasney,MD AlexSleeker,MD DanielDavis,MD JamesLinklater,MBBS AndrewSonin,MD KirlandDavis,MD AnthonyMascia,MD JasonStephenson,MD SukhvinderSinghDhillonMB,ChB, MRCP,FRCR JorgeMedina,MD D.DeanThornton,MD LaceyMoore,MD PhillipTirman,MD WilliamMorrison,MD JosephTriolo,MD KambizMotamedi,MD JorgeVidal,MD SethO’Brien,MD RichardWalker,MD CherylPetersilge,MD DavidWells,MD MichaelRichardson,MD LawrenceWhite,MD LouisSchruff,Jr,MD FaylanEsquivel,MD PeterT.Evangelista,MD DonaldJ.Flemming,MD ChristopherGoeser,DC,MD AngelAlbertoGomez,MD,MPH KennethLee,MD 13 Program Schedule Overview GeneralSessionwillbelocatedinArizonaBallroomunlessotherwisenoted. Sunday,March8,2015 7:00a.m.–7:55a.m. 7:00a.m.–5:00p.m. 7:00a.m.–1:30p.m. 7:00a.m.–4:30p.m. 7:45a.m.–8:50a.m. 9:00a.m.–10:15a.m. 10:15a.m.–10:20a.m. 10:20a.m.–10:45a.m. 10:45a.m.–12:10p.m. 12:10p.m.–12:15p.m. 12:10p.m.–1:30p.m. 1:30p.m.–3:00p.m. 3:00p.m.–3:10p.m. 3:10p.m.–4:40p.m. 4:40p.m.–5:00p.m. Monday,March9,2015 7:00a.m.–7:55a.m. 7:00a.m.–12:35p.m. 7:00a.m.–12:30p.m. 7:00a.m.–12:30p.m. 7:45a.m.–8:00a.m. 8:00a.m.–10:00a.m. 10:00a.m.–10:05a.m. 10:05a.m.–10:30a.m. 10:30a.m.–12:30p.m. 12:30p.m.–12:35p.m. 1:00p.m.–3:00p.m. 6:00p.m.–6:30p.m. 6:30p.m.–9:30p.m. Tuesday,March10,2015 7:00a.m.–7:55a.m. 7:00a.m.–12:35p.m. 7:00a.m.–12:30p.m. 7:00a.m.–12:30p.m. 8:00a.m.–10:00a.m. 10:00a.m.–10:05a.m. 10:05a.m.–10:30a.m. 10:30a.m.–12:30p.m. 12:30p.m.–12:35p.m. Wednesday,March11,2015 7:00a.m.–7:55a.m. 7:00a.m.–12:30p.m. 7:00a.m.–10:30a.m. 7:00a.m.–10:30a.m. 8:00a.m.–10:00a.m. 10:00a.m.–10:05a.m. 10:05a.m.–10:30a.m. 10:30a.m.–12:30p.m. CONTINENTALBREAKFAST REGISTRATION/INFORMATIONDESKOPEN EXHIBITHALLOPEN EPOSTERSESSION ANNUALBUSINESSMEETING INTERVENTIONSESSION CASEOFTHEDAY BREAK–VISITEXHIBITHALL LOWEREXTREMITY/OTHERSESSION CASEOFTHEDAY LUNCH(inExhibitHallorIndustrySponsoredLunchSymposium) FOCUSSESSION/SELFASSESSMENTMODULEI:ImagesoftheFootandAnkle BREAK–VISITEXHIBITHALL FOCUSSESSION/SELFASSESSMENTMODULEII:CurrentSocioeconomicIssuesinMSKImaging SAMExam CONTINENTALBREAKFAST REGISTRATION/INFORMATIONDESKOPEN EXHIBITHALLOPEN EPOSTERSESSION MSKRADIOLOGYRESIDENCYCOREANDADVANCEDELECTIVES KNEESESSION CASEOFTHEDAY BREAK–VISITEXHIBITHALL TUMORSESSION CASEOFTHEDAY *MUSCULOSKELETALULTRASOUNDHANDSONWORKSHOP:ELBOW *SeparateRegistrationRequired NEWMEMBERRECEPTION–MUMMYMOUNTAIN ANNUALBANQUET–MUMMYMOUNTAIN CONTINENTALBREAKFAST REGISTRATION/INFORMATIONDESKOPEN EPOSTERSESSION EXHIBITHALLOPEN UPPEREXTREMITYSESSIONI CASEOFTHEDAY BREAK–VISITEXHIBITHALL HIPSESSION CASEOFTHEDAY CONTINENTALBREAKFAST REGISTRATION/INFORMATIONDESKOPEN EXHIBITHALLOPEN EPOSTERSESSION UPPEREXTREMITIYSESSIONII CASEOFTHEDAY BREAK–VISITEXHIBITHALL TUMORII/OTHERSESSION 14 Industry Sponsored Lunch Symposium SundayMarch9th SponsoredbyBiomarin Dysostosis–isMPSonyourradar? I. TheimportanceoftheradiologistindiagnosingMPS:RalphLachman II. ClinicalOverviewofMorquioASymdromeandMPSVI:PaulHarmatz III. SurgicalTreatmentofLowerExtremityComplicatiomsofMucopolysaccharidoses:ScottHoffinger IV. DiscussionandQ&A RalphSLachman,MD Pediatric&GeneticRadiologist Codirector,Radiologic&ClinicalAnalyst,InternationalSkeletalDysplasiaRegistry RalphLachman,MDisProfessorEmeritusintheDavidGeffenSchoolofMedicineattheUniversityofCalifornia,LosAngeles& ClinicalProfessor,StanfordUniversity. HeisboardcertifiedinPediatrics,DiagnosticRadiologyaswellasaCAQ[subspecialtyboard]inPediatricRadiology.Hehelpedco foundwithDavidRimointheInternationalSkeletalDysplasiaRegistryin1970.Hismajorinterestshavealwaysbeeninskeletal dysplasias,genetic/radiologicalsyndromes/metabolicdisorders.Hehasauthored&coauthoredanumberofbooksincludingthe onlyradiologicaltextontheskeletaldysplasias,metabolicdisorders&syndromes.Dr.Lachmanhasauthoredover300peer reviewedpublications.Heis&hasbeenontheeditorialboardsofseveralmajorjournalsincludingtheAmericanJournalofMedical Genetics&PediatricRadiology.Hehasperformedalltheradiological/clinicalevaluationsofcasessenttotheISDRfromits’ conceptioninconsultationwiththeothermembersoftheISDRteamforthelast44years.Hehasreceivednumerousinternational honors&teachingawards. RalphLachmanremainsactiveafter“retirement”primarilywithhisISDRresearchwork[nowlocatedatUCLA],consultationsat LucilePackardChildren’sHospital,StanfordUniversity&theKaiserOakland/OaklandChildren’sHospitalcombinedSkeletal DysplasiaClinicinNorthernCalifornia.HehasbeenonthemedicaladvisoryboardfortheLPAformanyyears. PaulR.Harmatz,MD AssociateDirectorofthePediatricClinicalResearchCenteratUCSFBenioffChildren’sHospitalOakland,Oakland,CA Dr.HarmatzreceivedhisBAfromStanfordUniversityandMDfromDartmouthMedicalSchool,Hanover,NewHampshire.He completedhisinternshipandresidencytraininginPediatricsatHarborUCLAMedicalCenter,Torrance,CA.Followingaresearch fellowshipinPediatricGastroenterologyandNutritionatMassachusettsGeneralHospitalinBoston,MA,heremainedinBostonas facultymemberinPediatricsatHarvardMedicalSchool. Duringthelast10years,Dr.Harmatzhasparticipatedinclinicaltrialswithpatientswithmucopolysaccharidosis(MPS)I,II,VIandVIa andhasmanagedclinicalcareforMPSpatientslivinginnorthernCalifornia. Hehaswrittenover200originalscientificarticles,bookchaptersandabstractsongastrointestinalimmunophysiology,ironoverload, sicklecelldisease,betathalassemia,andlysosomalstoragediseases. ScottHoffinger,MD AssociateProfessorOrthopaedicSurgery,StanfordUniversitySchoolofMedicine AssociateDirectorPediatricOrthopaedics,LucilePackardChildren’sHospital Dr.HoffingerreceivedbothhisBAandMDfromUniversityofMichigan,AnnArbor.HecompletedhisInternship/AssistantResidency inGeneralSurgeryatYaleUniversityNewHavenMedicalCenterandcompletedhisFellowshipinPediatricOrthopaedicsat UniversityofCalifornia,DavisMedicalCenterunderDrsGeorgeT.RabandDanielRBenson. Dr.Hoffingerisanexpertintreatingskeletaldysplasiasandalsointreatingcerebralpalsy.HeisanactivememberofAAOS,POSNA. HehasbeenavisitingprofessorintheUSandgloballyincountriessuchasIraq,Indonesia,Vietnam,andBelgium.Hehaspublished numerousarticlesinpeerreviewedorthopedicjournalsandbookchaptersinvariousaspectsoforthopedics. 15 16 Sunday Saturday, March 7, 2015 4:00p.m.–6:00p.m. Registration/InformationDeskOpen Location:ArizonaBallroomNorth Sunday, March 8, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 7:00a.m.–7:55a.m. ContinentalBreakfast 7:00a.m.–1:30p.m. ExhibitHallOpen 7:00a.m.–5:00p.m. Registration/InformationDeskOpen 7:00a.m.–4:30p.m. ePosterSession* *Asthissessionisnotmoderated,ePostersarenotCMEaccredited 7:45a.m.–8:50a.m. AnnualBusinessMeeting* *8:30a.m.AwardsPresentation 9:00a.m.–10:20a.m. INTERVENTIONSESSION Moderators:BrianPetersen,MD;HumbertoRosas,MD 9:00a.m. #1 ULTRASOUNDGUIDEDTREATMENTFORREFRACTORYPLANTARFASCIOPATHY: ARANDOMIZEDCONTROLLEDPILOTSTUDYOFPLATELETRICHPLASMAVERSUSSTANDARDOF CARECORTICOSTEROIDINJECTIONS KennethLee;JohnWilson;SarahKohn;ElizabethPlovanich;RayVanderby (Presentedby:KennethLee,MD) 9:20a.m. #2 9:35a.m. #3 FLUOROSCOPICGUIDEDSACROILIACJOINTINJECTIONSCOMPARISONOFINTRAARTICULAR ANDPERIARTICULARINJECTIONSONIMMEDIATEANDSHORTTERMPAINRELIEF NicholasNacey,MDMichaelG.Fox;JamesPatrie (Presentedby:NicholasNacey,MD) UTILITYOFBONEBIOPSYOFSUSPICIOUSLESIONSINPATIENTSWITHKNOWNPRIMARY MALIGNANCYUTILITYOFBONEBIOPSYOFSUSPICIOUSLESIONSINPATIENTSWITHKNOWN PRIMARYMALIGNANCY DarrenFitzpatrick;MicahCohen;AlexMaderazo (Presentedby:DarrenFitzpatrick,MD) 9:55a.m. #4 ACCURACYOFHIGHRESOLUTIONULTRASONOGRAPHYINTHEDETECTIONOFHANDEXTENSOR TENDONLACERATIONS MihraS.Taljanovic;BobbyDezfuli;DavidM.Melville;ElizabethA.Krupinski;JosephE.Sheppard (Presentedby:MihraTaljanovic,MD) 17 Sunday, March 8, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 10:15a.m.–10:20a.m. CASEOFTHEDAY (Presentedby:AndrewC.Cordle,MD;CarolL.Andrews,MD) 10:20a.m.–10:45a.m. Break–VisitExhibitHall 10:45a.m.–12:10p.m. 10:45a.m. #5 LOWEREXTREMITY/OTHERSESSION Moderators:CarlWinalski,MD;AndrewPalisch,MD PREDICTIVEMRICORRELATESOFLESSERMETATARSOPHALANGEALJOINT(MPJ)PLANTAR PLATE(PP)TEAR HilaryUmans;RachelUmans;BenjaminUmans;ElisabethElsinger (Presentedby:HilaryUmans,MD) 11:05a.m. #6 MAGNETICRESONANCEIMAGINGDIAGNOSTICPERFORMANCEANDINTEROBSERVER VARIABILITYINSINUSTARSISYNDROME AbhijitDatir;RyanOwen;JadChamieh;AparnaKakarala;MonicaUmpierrez;WaltACarpenter (Presentedby:AbhijitDatir,MD) 11:20a.m. #7 CORRELATIONOFFLUIDALONGTHELATERALROOTSOFTHEINFERIOREXTENSOR RETINACULUMWITHEXTENSORDIGITORUMLONGUSTENDON ChimereMbaJonas;ZehavaSadkaRosenberg;IgnacioMartinRossi (Presentedby:ChimereMbaJonas,MD) 11:35a.m. #8 DIFFUSIONTENSORMRIMAGINGOFQUADRICEPSMUSCULATUREINTHESETTINGOF CLINICALFRAILTYSYNDROME DavidMichaelMelville;JaneMohler;ElizabethKrupinski;MihraTaljanovic (Presentedby:DavidMelville,MD) 11:50a.m. #9 TRABECULAEBONESTRUCTUREANALYSISININDIVIDUALSAFFECTEDBYTYPE1GAUCHER DISEASEUSINGMICROMAGNETICRESONANCEIMAGING GulshanB.Sharma;DouglasRobertson;ElieHarmouche;MinzhiXing;DawnA.Laney;MichaelJ Gambello;JadChamieh;MichaelTerk (Presentedby:DougRobertson,MD) 12:05p.m.–12:10p.m. CASEOFTHEDAY: (Presentedby:RudraBarua,MD;MarkKransdorf,MD) 12:10p.m.–1:30p.m. Lunch OptionalIndustrySponsoredLunchPresentation Dysostosis–isMPSonyourradar? SponsoredbyBiomarin Seepage15fordetails 12:10p.m.–1:30p.m. 18 Sunday, March 8, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 1:30p.m.–3:00p.m. 1:30p.m.–2:00p.m. 2:00p.m.–2:30p.m. 2:30p.m.–3:00p.m. FocusSession/SelfAssessmentModuleI:ImagingoftheFoot&Ankle Moderator:HilaryUmans,MD;ZehavaRosenberg,MD SpringandLisfrancLigaments (Presentedby:ZehavaRosenberg,MD) Metatarsalgia:ForefootImagingandPlantarPlateTear (Presentedby:HilaryUmans,MD) ImagingofthePostOperativeFootandAnkle (Presentedby:JamesLinklater,MBBS) 3:00p.m.–3:10p.m. Break 3:10p.m.–4:40p.m. FocusSession/SelfAssessmentModuleII:CurrentSocioeconomicIssuesinMSKImaging Moderator:JonathanLuchs,MD 3:10p.m.–3:30p.m. Radiology&MedicalMalpractice (Presentedby:JonathanLuchs,MD) 3:30p.m.–3:50p.m. 3:50p.m.–4:10p.m. MusculoskeletalImaging:DoomedforCommoditization (Presentedby:PaulHarkey,MD) AccountableCareOrganizations:HowthePracticingRadiologistCanPrepareandAdapt (Presentedby:JonathanFlug,MD,MBA) 4:10p.m.–4:30p.m. ChallengesforRadiologistsintheAgeofAccountableandAffordableCare (Presentedby:S.Yadavalli,MD,PhD) 4:30p.m.–4.40p.m. QuestionsandAnswers 4:40p.m.–5:00p.m. SAMExam 19 Related ePosters FullePosterAbstractsareonPage165 Interventional ePoster#1 ANEWMSKAPPLICATIONOFMICROWAVEABLATION PritiPatil;KennethLee UniversityofWisconsin ePoster#2 SUBCHONDROPLASTY:ANEWMINIMALLYINVASIVEPROCEDUREFORTREATMENTOFKNEE PAINASSOCIATEDWITHARTHRITIS AlisinaShahi;WilliamMorrison;AdamZoga;JohannesRoedl;PeterWahba ThomasJeffersonUniversity ePoster#3 ARTHROCENTESIS:AMULTIMODALITYAPPROACH CorrieM.Yablon,NathanielBMeyer,JimSWuMD,YoavMoragMD, SungMoonKimMD,DavidPFessellMD,JonAJacobsonMD UniversityofMichigan ePoster#4 ULTRASOUNDGUIDEDANTERIORSCALENEMUSCLEINTERVENTIONSFORDIAGNOSTIC EVALUATIONANDTREATMENTOFTHORACICOUTLETSYNDROME MichaelG.Rodriguez;MasonB.Frazier;BenjaminTriche;TatumA.McArthur,PhikipChapman, MD UniversityofAlabamaatBirmingham ePoster#5 CTGUIDEDLUMBARFACETSYNOVIALCYSTINTERVENTION:WHATTHERADIOLOGISTNEEDS TOKNOW TatumA.McArthur;JessicaL.Millsap;NicholasG.Clayton;ZacharyLambertsen;CarlA.Narducci UniversityofAlabamaatBirmingham ePoster#6 ASSESSMENT OF TENDON AND TENDON SHEATH PATHOLOGY FOLLOWING THERAPEUTIC INJECTION:THETENOSONOGRAPHICEFFECT JenniferLMcOsker;RonaldSAdler;GinaCiavarra;RenataLaRoccaVieira;JamesBabb NewYorkUniversityLagoneMedicalCenter LowerExtremity/Other ePoster#7 NORMALSKELETALDEVELOPMENTANDIMAGINGPITFALLSOFTHECALCANEALAPOPHYSIS: MRIFEATURES Ignacio Martin Rossi; Zehava Sadka Rosenberg; Chimere MbaJonas; Jonathan Zember; ChristopherMorley;AnneWang NewYorkUniversityLagoneMedicalCenter ePoster#8 THEHIDDENSECRETSOFTHEAPRADIOGRAPHOFTHEANKLE IgnacioMartinRossi;ZehavaSadkaRosenberg;JonathanZember NewYorkUniversityLagoneMedicalCenter ePoster#9 CHARCOTFOOT:THESPECTRUMOFFINDINGS,WITHANEMPHASISONSOFTTISSUECHANGES SayedAli;ParthaHota TempleUniversity ePoster#10 POSTEROMEDIALEXTRAARTICULARCOALITION:POORLYRECOGNIZEDANDUNDER DIAGNOSEDENTITYINTHEHINDFOOT CatherinePetchprapa;ZehavaRosenberg NewYorkUniversityLagoneMedicalCenter 20 Related ePosters FullePosterAbstractsareonPage165 ePoster#11 FOOTARTHRODESISHARDWARE:AREVIEW Tatum A. McArthur; Jessica L. Millsap; Angel A. GomezCintron; Saurabh Gupta; Michael G. Rodriguez UniversityofAlabamaatBirningham ePoster#12 POSTERIORTIBIALTENDONDYSFUNCTION,THESPRINGLIGAMENT,ANDACQUIREDPES PLANUS TatumA.McArthur;AngelA.GomezCintron;AnandPatel;MichaelG.Rodriguez UniversityofAlabamaatBirmingham ePoster#13 “LEOPARDSPOTEDEMA”:ANOSSEOUSSTRESS,HEALINGANDREINJURYPHENOMENONIN PROFESSIONALBALLETDANCERSSEENONMR FelixGonzalez;BethanyCasagranda;PhilipColucci;JohannesRoedl;WilliamB.Morrison;Adam Zoga Thomas Jefferson University; Allegheny Health Network; New York University Lagone Medical Center ePoster#14 POSTERIORTIBIALDYSFUNCTION:IMAGINGDIAGNOSISWHENNOMRIDETECTABLETENDON PATHOLOGYISPRESENT ElieHarmouche;DouglasRobertson;AparnaKakarala;SethMeans;MinzhiXing;MichaelTerk EmoryUniversity ePoster#15 MRIANDCLINICALEVALUATIONOFACCESSORYNAVICULARBONETYPES JadChamieh;SimaBanerji;DouglasRobertson;ElieHarmouche;SamehLabib;MichaelTerk EmoryUniversity ePoster#16 ULTRASOUNDANDMUSCLE:AMATCHWITHLONGTERMPOTENTIAL MichelleMcNee;BenjaminLevine;BenjaminPlotkin;KambizMotamedi;JordanGross UCLAHealthSystem 21 Podium #1 ULTRASOUNDGUIDEDTREATMENTFORREFRACTORYPLANTARFASCIOPATHY:ARANDOMIZEDCONTROLLEDPILOTSTUDYOF PLATELETRICHPLASMAVERSUSSTANDARDOFCARECORTICOSTEROIDINJECTIONS KennethLee;JohnWilson;SarahKohn;ElizabethPlovanich;RayVanderby UniversityofWisconsin (Presentedby:KennethLee) Objective:Toinvestigateifultrasound(US)guidedplateletrichplasma(PRP)injectioniseffectivefortreatingmoderatetosevere plantarfasciopathy(PF)comparedtostandardofcarecorticosteroid(SOC)injection. Methods: IRB approval and informed consent were obtained. Inclusion and exclusion criteria were met, which mostly involved unilateral PF, failed conservative therapy, and VAS pain level of at least 5 of 10 point scale. 44 consecutive subjects were block randomizedintotwotreatmentgroups–PRPandSOC.PRPsubjectsreceivedasingleinjectionofautologousPRPatweek0.SOC subjectsreceivedasingleinjectionoftriamcinolone40mgatweek0.VASpainlevelsandUSmorphologychangesofPFthickness, hypoechogenicity(grade03),andhyperemia(grade03)wereobtainedatweek0(preinjection)andatweeks16and32(post injection).Analysisofcovariancewasusedforstatisticalanalysis.Statisticalsignificancewasdeterminedatpvalue<0.05. Results:23SOCsubjects(meanage49.2yrs;range3064),M:F(7:16)and21PRPsubjects(meanage47.8yrs;range3064),M:F(4:17) completed the 32week longitudinal study from March 2011 through July 2014. Baseline VAS pain levels were not statistically significant (6.4 in PRP vs 5.8 in SOC; p=0.4). Baseline US morphology changes were also not statistically significant except for hypoechogenicity(2.80inPRPvs1.79inSOC;p<0.002).At16and32weeks,bothgroupsshowedimprovementinVASpainlevels comparedtobaseline,butPRPshowedgreaterimprovementthanSOCovertime(decreaseof0.42;SD0.12inPRPvs0.23;SD0.08in SOC; p=0.0006). PF thickness decreased (mean of 0.33 mm; p=0.0001) in both groups over time (p=0.09). Hypoechogenicity also improvedinbothgroups,butPRPshowedgreaterimprovementthanSOCovertime(decreaseof0.42;SD0.13inPRPvs0.004inSOC; p=0.003).Hyperemiadidnotchangeovertimeforbothgroups. Conclusion:ThisrandomizedcontrolledpilotstudydemonstratedthatUSguidedPRPinjectionmaybeaneffectivetreatmentfor refractoryPFcomparedtoSOCsteroidinjections.However,largerscalemultiarmedstudiesarenowneededtohelpestablishanew standardofcaretherapy. 22 Podium #2 FLUOROSCOPICGUIDEDSACROILIACJOINTINJECTIONSCOMPARISONOFINTRAARTICULARANDPERIARTICULARINJECTIONS ONIMMEDIATEANDSHORTTERMPAINRELIEF NicholasC.NaceyM.D.,JamesT.PatrieMS.,MichaelG.Fox,M.D. UniversityofVirginia (Presentedby:NicholasC.Nacey,MD) Purpose:Todetermineifintraarticularsacroiliac(SI)jointinjectionsprovidegreaterimmediateandshorttermpainreliefcompared toperiarticularSIinjections. MaterialsandMethods:AllfluoroscopicguidedSIjointsinjectionstargetingtheinferior1cmoftheSIjoint,performedovera4year period, were identified. Patients injected with Bupivacaine and 20 mg of triamcinalone were included. Patients were excluded if anothertriamcinalonedoseoradifferentsteroid/anestheticcombinationwasused,orifthepre,immediateor1weekpostinjection painscorewasnotrecorded.AnMSKradiologistwith13yearsexperienceretrospectivelyreviewedthefluoroscopicinjectionimages todetermineintraorperiarticularplacement.MannWhitneyandmultivariatestatisticalanalysiswasperformed. Results: 170 patients (115F:55M; mean age 60.9 years) met the inclusion criteria with 95 intra and 75 periarticular. Injection indications included: Sacroilitis (n=37), Low back pain (n=57), Pelvic pain (n=19), Sacral disorder (n=52) and other (n=5). The Bupivacainedosewaseither0.25%(n=71)or0.5%(n=99).Pre,immediateand1weekpostinjectionpainscoresfortheintraand periarticular injections were 6.1/1.9/4.0 and 6.1/2.5/4.3 respectively. Immediate and 1week postinjection pain reduction was statisticallysignificantinbothgroups(p=<0.001).Afteradjustingforage,genderandprepainlevel,therewasnosignificantdifference in the preinjection to immediate postinjection change in pain between intra and periarticular injections using Bupivacaine 0.25%(meanchange0.33[95%CI0.67,1.34;p=0.51)orBupivacaine0.5%(meanchange0.61[95%CI0.24,1.47;p=0.16)orinthepre to1weekpostinjectionchangeinpain(meanchange0.23[95%CI0.43,0.88;p=0.50].Medianfluoroscopictimefortheintraarticular injectionswas27secondsandfortheperiarticularinjectionswas47seconds(p=0.002) Conclusion:BothintraandperiarticularSIjointinjectionsprovidestatisticallysignificantimmediateand1weekpostinjectionpain relief.Nosignificantdifferenceinthedegreeofpainreliefprovidedbyintraandperiarticularinjectionswasfound. 23 Podium #3 UTILITYOFBONEBIOPSYOFSUSPICIOUSLESIONSINPATIENTSWITHKNOWNPRIMARYMALIGNANCY DarrenFitzpatrick;MicahCohen;AlexMaderazo MountSinaiRadiologyAssociates (Presentedby:DarrenFitzpatrick) Purpose:Thepurposeofourretrospectivestudyistoevaluatetheincidenceofdetectionofasecondarymalignancyinpatient’swith aknownprimarymalignancywhohaveasolitary,aggressiveosseouslesion. Methods&Materials:Medicalrecordsandimagingof453patientsundergoingCTguidedbonebiopsyatourinstitutionovera4year period(1/1/111/31/14)wereretrospectivelyreviewedforhistoryincludingknownhistoryofmalignancy,siteofbiopsyandpathology results of biopsied specimen. Biopsied lesions in patients with a known malignancy were retrospectively characterized by a musculoskeletal radiology attending as aggressive or notaggressive appearing based on the presence of cortical destruction, aggressiveperiostealreaction,trabecularrarefactionormottling. Results:OnehundredfortytwopatientswerefoundtohaveahistoryofpreviousknownmalignancyandCTguidedbiopsy.Ofthese patients,89werefoundtohaveaggressiveosseouslesions.26werefoundtohavemultifocalosseousdisease(allexceptfourbiopsies confirmeddiagnosisoftheprimarymalignancy).TwentysevenpatientswerefoundtohavescleroticornonaggressivelesionsonCT; 16ofthesebiopsiesconfirmeddiscordantoralternativediagnoses.SevenofhadalternativediagnosesonprebiopsyCTthatwere confirmedpathologicallyand9patientshaddiscordantdiagnoses.Ofthe89patientswithaggressiveosseouslesionsonCT,8had discordantfindingsdifferentfromtheprimarymalignancy,revealinganew,secondarymalignancy. Conclusions:Thevastmajorityofpatientsatourinstitutionundergoingbonebiopsywiththehistoryofaknownmalignancywere foundtohaveosseousmetastasesoftheirprimarycancers.Withtheproperstratificationofpatientswithaggressiveappearinglesions andknownprimarymalignancy,thereislimitedutilityofexposingpatientstothemorbidityandcostsofabonebiopsyprocedure giventheunlikelihoodofpathologyindicatingabenignlesionorsecondmalignancy.Patientswithmultifocalosseousdiseasealsohad ahighrateofmetastasesfromtheprimarymalignancy.Patientswithnonaggressiveorscleroticbonediseasehaveahighrateof discordant and benign lesions and should be biopsied. Clinical Relevance/Application: With the proper selection of patients with knownprimarymalignanciesandaggressiveosseouslesions,thereislimitedutilitytoperformingbonebiopsygiventherelativelylow likelihoodoffindingabenignlesionorsecondmalignancy.Theclinicalimplicationsofourfindingsincludedecreasedmorbidityto patientsandcosttosocietyintheappropriateclinical/imagingsetting. 24 Podium #4 ACCURACYOFHIGHRESOLUTIONULTRASONOGRAPHYINTHEDETECTIONOFHANDEXTENSORTENDONLACERATIONS MihraS.Taljanovic;BobbyDezfuli;DavidM.Melville;ElizabethA.Krupinski;JosephE.Sheppard UniversityofArizonaHealthNetwork (Presentedby:MihraS.Taljanovic) Purpose:Toassesstheaccuracyofhighresolutionultrasound(US)examinationtodetecttheextensortendoninjuriesinthehandand determinetheaddedvalueofrealtimeanddynamicUSimaginginevaluationoftheseinjuries. MaterialsandMethods:Sixtyeighttransverseskinlacerationswerecreatedbyaseniororthopaedicsurgeryresidentin16fingers and4thumbsof4freshfrozenandthawedcadaverichands.Twentysevenextensortendonsorextensormechanismweresharply transected.Specifically,4terminalextensortendons,4centralslips,4sagittalbands,4extensorpollicislongus,1extensorpollicis brevis,2extensorindicisproprius,1zoneII,2zoneIII,2zoneIV,and1zoneVextensordigitorumcommunis,and2extensordigiti minimitendonsweretransected.Theremaininglacerationswereusedasshamdissectioncontrolsfortheevaluationof57intact extensortendonsites.Skinlacerationswere0.5cminsize.RealtimedynamicUSexaminationofthecadavericdigitswasperformed inandoutofwaterbathonLogicE9GeneralElectricultrasoundmachinewithhighresolution818MHzmultifrequencylinear"hockey stick"transducerandinterpretedbyasinglemusculoskeletal(MSK)radiologistinconjunctionwithasingleUStechnologist.Selected staticimageswererecorded.Theinterpretingradiologistwasblindedfordissectionfindings.Toassessthevalueofrealtimeand dynamicimaging,thestaticimagesweresubsequentlyreviewedbyasecondobserver,anotherfellowshiptrainedMSKradiologist whowasblindedtotheinitialUSinterpretationanddissectionfindings.TheresultsoftheUSexaminationsandsurgicaldissections werecompared.ThestatisticalanalysiswasperformedbytheFisherexacttest.Statisticalsignificancewassetatp<0.05.Sensitivity, specificity,andaccuracyoftherealtimedynamicandstaticUSimagingwereassessed. Results:OninitialinterpretationwithbenefitofrealtimeanddynamicUSimaging,all27extensortendonlacerationsandremaining 57intactcontrolswereidentifiedcorrectlyaseithertransectedorintactwith100%sensitivityandspecificity,andapositivepredictive valueof1.0.SubsequentinterpretationofstaticUSimaginghadasensitivityof85%,specificityof89%,andaccuracyof88%.The resultsoftherealtimeanddynamicUSimagingandtheevaluationofonlystaticimagingwereclearlydifferentbutdidnotreach statisticalsignificance. Conclusion: Highresolution US examination provides accurate evaluation of hand extensor tendon injuries, with realtime and dynamicimagingprovidingaddeddiagnosticvalue. 25 Podium #5 PREDICTIVEMRICORRELATESOFLESSERMETATARSOPHALANGEALJOINT(MPJ)PLANTARPLATE(PP)TEAR HilaryUmans;RachelUmans;BenjaminUmans;ElisabethElsinger LenoxHillRadiology&ImagingAssociates (Presentedby:HilaryUmans) PURPOSE:ToidentifyqualitativeandquantitativeMRIfindingscorrelatedwithlesserMPJPPtear. METHODANDMATERIALS:NoncontrastMRI(10/201201/2014,1.5or3.0T)of50PPtearcases(35female,15male,av52yrs)and 50controls(41female,9male,av35yrs)wererandomizedandreviewed.AllcasesofPPteardemonstratedacceptedMRIcriterion ofabrightT2signaldefectattheinsertionofthePP.AnMSKradiologist,blindedtodiagnosis,reviewedpotentialqualitativecorrelates ofPPtearincluding:metatarsal(MT)axisrotation,toedeviation,intermediatesignalpericapsularsofttissuethickening(STT),toe enthesitisandflexortendonsubluxationortenosynovitis.Atrained,similarlyblindednonphysician,unfamiliarwithMRIdiagnosisof PPtear,measuredMTaxisrotation,2ndMTprotrusion,submetatarsalfatpadthicknessandtoerotation.Eachblindlydoubleread 20MRI(11cases,9controls)toevaluateintraobserveragreementforthequalitativefindingsandquantitativemeasures,respectively. Kappastatistic,ttest,Wilcoxonranksumtestwereusedasappropriate;p<0.05wasconsideredsignificant.Classificationtreeswere createdtoidentifycombinationsoffindingscorrelatedwithPPtear. RESULTS:Thereweresignificant,reproducibledifferencesinmeasuredMTaxisrotationand2ndMTprotrusionbetweenPPtearand controlgroups.LesserMTsupination>36°or2ndMTprotrusion>4mmtrendtowardacorrelationwithPPtear.LesserMTsupination <24°isastrongnegativepredictorofPPtear.LesserMTprotrusion>4.5mmisastrongpositivepredictorofPPtear.Amongqualitative correlates,pericapsularSTTcorrectlyclassified95%ofcasesandcontrols,thoughtheremaybeanelementofdiagnosticheterogeneity in assessment of this finding. Excluding pericapsular STT, 94% correct classification was achieved by a combination of 2nd toe enthesitis,2ndflexortendonsubluxationandsplayingofthe2ndand3rdtoes.Bothquantitativemeasures(concordance=0.880.99) andqualitativeassessments(kappa=0.711.0)werehighlyreproducible. CONCLUSION:PPtearcanbedeterminedwithhighaccuracyusingacombinationofcorrelatedqualitativefindingsandquantitative measurements. 26 Podium #6 MAGNETICRESONANCEIMAGINGDIAGNOSTICPERFORMANCEANDINTEROBSERVERVARIABILITYINSINUSTARSISYNDROME AbhijitDatir;RyanOwen;JadChamieh;AparnaKakarala;MonicaUmpierrez;WaltACarpenter EmoryUniversityHospital (Presentedby:AbhijitDatir) Purpose:Thepurposeofthisstudyis–(1)ToevaluatethediagnosticperformanceofMRIinsinustarsisyndrome(STS),(2)Toassess thesensitivity,specificity,positivepredictivevalue(PPV)andnegativepredictivevalue(NPV)ofindividualfindingsinthediagnosisof STS,and(3)TostudyinterobservervariabilityoffindingsseenonMRIinpatientswithSTS. Materials and Methods: We retrospectively searched reports of ankle and hindfoot MRI studies performed at a single tertiary musculoskeletalimagingcenterforthekeywordssinustarsisyndrome(STS),donebetweenJanuary2011andAugust2014.Atotalof 1372studieswerereviewed,outofwhich86weresuspiciousforSTS,eitherclinicallyorradiologically.Outofthese,32wereexcluded duetolackofclinicalfollowupandfinalclinicaloutcome.Theremaining54patientswereincludedinthisstudy,22females(mean age56years,range3775)and32males(meanage47years,range2177).Threefellowshiptrainedmusculoskeletalradiologists, blindedtotheclinicalindication,originaldiagnosticimpressionandthefinalclinicaloutcome,individuallyreviewedtheseMRIs.All MRIstudieswerereviewedforspecificfindingsincludingtheSTfatsignal,thecervicalligament(CL),theinterosseoustalocalcaneal ligament(ITCL),thepresenceoffluidinoraroundtheST,associatedosseousmarrowedema,andthepresenceofsynovitis.Thefinal diagnosis of STS was based on either arthroscopy or pain resolution following appropriate treatment. Statistical analysis was performed using Fleiss’kappa test (K) toassess interobserver variability for the aforementioned MRI findings.We alsocalculated sensitivity,specificity,PPVandNPVfortheseindividualfindings,andoverallPPVofMRIinthediagnosisofSTS.Thecriterionfor statisticalsignificancewasp<0.05. Results:Therewasfairinterobserveragreement(K=0.210.40)forallfindingsexceptforthepresenceofsynovitisandfluidoutside theST.ThesensitivitywashighestforfluidoutsidetheST(100%),followedbySTfatabnormalityandtornITCL(both83%).Similarly, thespecificityforSTSdiagnosiswashighestforthepresenceofsynovitis(98%)followedbytornCL(54%).Overall,thePPVofMRIin thediagnosisofSTSwasonly11%. Conclusion:WeconcludethatMRIyieldsapoorPPVwithonlyfairinterobserveragreementforindividualMRIfindingsinthediagnosis ofSTS.ThefindingsoffluidoutsidetheSTandsynovitiswerethemostsensitiveandspecificinthediagnosisofSTSrespectively. However,thesefindingsdemonstratedthelargestinterobservervariability,thustheirdiagnosticutilityisquestionable.Wepropose that MRI may provide an excellent overall visualization of soft tissues in the evaluation of STS, but currently lacks in diagnostic performance.FurtherresearchisneededtoestablishamoreaccurateandreproduciblesetofMRIcriteriainthediagnosisofSTS. 27 Podium #7 CORRELATIONOFFLUIDALONGTHELATERALROOTSOFTHEINFERIOREXTENSORRETINACULUMWITHEXTENSORDIGITORUM LONGUSTENDON ChimereMbaJonas;ZehavaSadkaRosenberg;IgnacioMartinRossi NewYorkUniversity/HospitalforJointDisease (Presentedby:ChimereMbaJonas) Purpose:Thelateralrootsoftheinferiorextensorretinaculum(IER)normallyformaslingaroundtheextensordigitorumlongus(EDL) tendon.Thus,fluidsurroundingtheroots,astheyoriginatefromthesinustarsi,canapproximatetheextensordigitorumlongustendon (EDL), at times simulating tenosynovitis or bursal fluid collection. The purpose of this study was to further assess this, previously undescribed,phenomenon,andtoalerttheradiologisttothepotentialpitfallofoverdiagnosingtenosynovitisorbursaoftheEDL. MaterialsandMethods:258ankleMRIcasesincluding158studiesidentifiedviaqueryingourdigitaldatabaseandourteachingfiles, using the key phrases “extensor digitorum longus tenosynovitis” and “sinus tarsi ganglion” as well as 100 consecutive ankle MRI examinationswereretrospectivelyreviewedforthepresenceofsinustarsifluid,alongtherootsoftheretinaculum,extendingtoward the EDL. Additional osseous or soft tissue findings such as ligament tears, tendon disease and osseous pathology were also documented.Allcases(n=1),withgivenclinicalhistoryoftendonpathologyattheEDL,wereexcluded. Results:Atotalof31ankleMRIstudies(11males,20female,agerange2983,meanage54),withfluidextendingfromthesinustarsi, alongthelateralrootsoftheIER,towardtheEDL,wereidentified.Theseincluded15caseswithganglionsand16caseswithnon encapsulatedfluidwithinthesinustarsi.Theganglia/fluidatthesinustarsitypicallysurroundedboththeinferiorandsuperioraspects ofthelateralrootsoftheIER.In1casethefluidcircumferentiallysurroundedtheEDL,suggestingtruetenosynovitis.In30othercases (97%)thefluidwasnotedtoaccompanythelateralrootsoftheretinaculum,fromthesinustarsi,towardthemedial,lateraland/or undersurfaceoftheEDL,withoutfullysurroundingthetendonandwithoutdistensionofthetendonsheath.Mostcommonassociated findingsincludedligamentousinjury(n=10),posteriortibialtendon(PTT)dysfunction(n=9),flatfoot(n=6)andosteoarthrosis(n= 4). Conclusion: Fluid within the sinus tarsi, whether encapsulated or not, can extend along the lateral roots of the IER and partially surroundtheEDL.ThisphenomenonisoftenseenwithligamentoustearsorPTTdysfunctionandshouldnotbeoverdiagnosedas tenosynovitisorbursaalongtheundersurfaceoftheEDL. 28 Podium #8 DIFFUSIONTENSORMRIMAGINGOFQUADRICEPSMUSCULATUREINTHESETTINGOFCLINICALFRAILTYSYNDROME DavidMichaelMelville;JaneMohler;ElizabethKrupinski;MihraTaljanovic UniversityofArizonaCollegeofMedicine (Presentedby:DavidMichaelMelville) Purpose:Frailtyisacommongeriatricsyndromeassociatedwithsarcopenia,orthelossofskeletalmusclemassanddensity,conferring anincreasedriskofrapiddeclineinhealthandfunctionandvulnerabilityforadverseoutcomes.Thedevelopmentofdiagnostictools andbiomarkersforclinicalfrailtysyndromeenhancesunderstandingandtreatmentofthiscommoncondition.Thepurposeofthis studywastoinvestigatethecorrelationofdiffusiontensorvaluesofthequadricepsmusclegroupbetweenfunctionalcategoriesof frailtysyndromeusingdiffusiontensormagneticresonanceimaging. MaterialandMethods:SubjectswererecruitedfromasubsampleoftheArizonaFrailtycohortcomposedofallfemaleswithfrailty statusbasedonFriedcriteria,including6nonfrailand10prefrail/frailadults,aswellasacommunitysampleof11young,healthy controls.Axialimagesofboththighswereobtainedona3TmagnetwithT1,T2anddiffusiontensorimaging,aswellasintramuscular fatcontentanalysis.DiffusiontensorindicesandT2valuesweredeterminedbyregionofinterestmeasurementsattheproximal,mid anddistalthirdsofboththighs.Datawereevaluatedtodeterminethedifferencesbetweenmeasuredvaluesandfrailtystatus. Findings:Afinalstudygroupof26subjectsconsistedof11young,healthycontrols(23.3+3.0yearsold,135.4+17.9pounds),6non frailsubjects(72.8+4.6yearsold,128.2+11.5pounds),and9prefrail/frailsubjects(81.3+8.8yearsold,155.6+40.5pounds). Overall, the mean fractional anisotropy (FA) values in the bilateral quadriceps muscles demonstrated a significant difference (p = 0.0030)betweenthecontrolandprefrail/frailandnonfrailandprefrail/frailgroupsandT2relaxationtime(p<0.0001).Therewasa significantdifference(p<0.001)inaveragelipidcontentbetweenall3groupsandapositivecorrelationbetweenage. Conclusion:Thequadricepsmusculatureofprefrail/frailadultsdemonstratedincreasedFAcomparedtoyoungcontrolsandnonfrail adultsreflectingfrailtyrelatedincreasedintramuscularfatcontentandotherpotentialmusclearchitecturalchanges. 29 Podium #9 TRABECULAEBONESTRUCTUREANALYSISININDIVIDUALSAFFECTEDBYTYPE1GAUCHERDISEASEUSINGMICROMAGNETIC RESONANCEIMAGING GulshanB.Sharma;DouglasRobertson;ElieHarmouche;MinzhiXing;DawnA.Laney;MichaelJGambello;JadChamieh;Michael Terk EmoryUniversitySchoolofMedicine (Presentedby:DouglasRobertson) Introduction: An estimated 70%100% of Gaucher disease individuals having at least one N370s allele (type 1) exhibit bone deficiencies. Specifically affected are bone marrow organization and composition, cortical and trabecular bone, and bone vascularization.StudiesexaminingearlyimpactofGaucherdiseaseonboneaswellastheefficacyofitstreatmentislimitedbythe sensitivityofvalidatedimagingtechniquesavailable.ThepurposeofthisstudyistoutilizemicroMRIofthedistalradiustocharacterize trabecularbonemicroarchitectureinindividualsaffectedbyGaucherdisease.WehypothisethatGaucherbonetissueismechanically weakerthannormalanddifferencesmayexistbetweendifferentgenotypes. Methods:10Gaucherpatients(7females,3males,aged2271years)withknowngenotypewererecruitedforthestudyaswellas10 controls(5females,5males,aged2444years).Allunderwentvolumetric3DprotondensitymicroMRIofthewrist.Forthecentral sliceasquareregionequalingthemediolateralwidthofthebonewasconsideredandbonecentroidwascomputed,dividingitinto fourquadrants.Foreachquadrantthefollowingstereologicalpropertieswerecomputed:bonevolume(BV),trabeculaevolume(TV), trabeculaedensity(TD=TV/BV),normalizedtrabeculaelength(NTL=trabeculaelength/BV),trabeculaeseparation(TS),trabeculae thickness(TT),trabeculaeorientation(TO),trabeculaefractaldimension(TF)andtrabeculaeentropy(TEn).Twogeneralizedlinear modelswithtwomainfactorseachwerecreatedandpairwisecomparisonscheckedforstereologicalpropertiesdifferencesbetween patientsandcontrols,betweenthefourquadrants,andbetweenpatientsandcontrolsineachofthefourquadrants.Thesameanalysis was done for the different genotypes and quadrants. The level of significance was 0.05 with adjustments made for multiple comparisonsusingtheleastsignificantdifference. Results:ThepatientsshowedsignificantlygreaterTDandNTLcomparedtocontrolsoverallandinthefourquadrants(Table1).TT was approximately equal between patients and control; however, TS was significantly lower in patients. TF in patients was only fractionallygreaterthancontrolsbutshowedsignificanceoverall.TOwasnotsignificantlydifferentbetweenpatientsandcontrols; however, in quadrants 1 and 2 patients showed greater variance compared to controls. Patients with a second N370S allele had significantlylowerTDandNTLbutsignificantlygreaterTScomparedtoL444Pand84GGallelespatients(Figure2).TFwassignificantly higherinpatientswith84GGallelecomparedtoN370S,L444Pand55BPdeletion.Discussion:Gaucherboneismechanicallyweaker thannormalbone.Patientswithdifferentgenotypesshowdifferencesinstereologypropertiesaswell.VariationsinTD,NTL,TSand TFwereeithersignificantorshowedstrongtrendsbetweenpatientswithN370S,L444P,and84GGalleles.Thisshowsthatdetecting subtlechangesintrabeculaebonemicroarchitectureinGaucherpatientsusingmicroMRimagingisfeasibleforbothpreventionand treatment.Thisstudyisstillactiveandwillincorporatealargersampleofpatientsandcontrols. 30 31 32 Monday Monday, March 9, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 7:00a.m.–7:55a.m. ContinentalBreakfast 7:00a.m.–12:30p.m. ExhibitHallOpen 7:00a.m.–12:35p.m. Registration/InformationDeskOpen 7:00a.m.–12:30p.m. ePosterSession* *Asthissessionisnotmoderated,ePostersarenotCMEaccredited 7:45a.m.–8:00a.m. 7:45a.m. MSKRADIOLOGYRESIDENCYCOREANDADVANCEDELECTIVES #10 ANEEDSASSESSMENT CorrieM.Yablon,MD;BrianD.Petersen,MD;TheodoreT.Miller,MD;DonaldJ.Flemming,MD (Presentedby:CorrieM.Yablon,MD) KNEESESSION Moderators:TimSanders,MD;BethanyCasagranda,MD 8:00a.m. #11 MAGNETICRESONANCEIMAGING(MRI)INTHEDIAGNOSISANDMANAGEMENTOFINTERNAL DERANGEMENTOFTHEKNEE:DEVELOPMENTOFANEVIDENCEBASEDPREDICTIONMODEL NaveenSubhas;NancyObuchowski;AlexBenedick;AnnaDistaulo;AmitGupta;MorganJones (Presentedby:NareenSubhas,MD) 8:20a.m. #12 Baselinecartilagethicknessandmeniscusextrusionpredictlongitudinalcartilagelossby quantitativeMRI:datafromtheOAI JasonKlein;JeanJose;MichaelBaraga;TySubhawong (Presentedby:JasonKlein,MD) 8:40a.m. #13 SubchondralInsufficiencyFractureoftheKnee:RevisingtheEpidemiologyandSoftTissue EdemaPattern AndrewWilmot;AlexRuutiainen (Presentedby:AndrewWilmont,MD) 9:00a.m. #14 MAGNETICRESONANCEIMAGINGOFPOPLITEALDEEPVENOUSTHROMBOSISONROUTINE IMAGINGASSESSMENTOFTHEKNEE LawrenceWhite;RyanShulman;CraigBuchan;RobertBleakney (Presentedby:LawrenceWhite,MD) 9:15a.m. #15 Masslikestructureintheintercondylarnotch:"pseudolesion"orasentinellesion? TetyanaGorbachova;MinnSaing;RyanSmith;IgorGoykhman (Presentedby:TetyanaGorbachova,MD) 9:30a.m. #16 ComparinganAccelerated3DFastSpinEchoSequenceUsingCompressedSensing(CSSPACE) forKneeMagneticResonanceImaging(MRI)withTraditional3DFastSpinEcho(SPACE)and Routine2DSequences FaysalAltahawi;NicholasMorley;KevinBlount;ImranOmar (Presentedby:FaysalAltahawi,MD) 8:00am.–10:00a.m. 33 Monday, March 9, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 9:45a.m. #17 10:00a.m.–10:05a.m. EarlyBoneCurvatureChangesoftheKneeDetectedonMRICanPredictOAProgression:Data FromtheOAI Joshua M. Farber; Jose TamezPena; David Hunter; Michael Hannon; Saara Totterman; Zhijie Wang;RobertBoudreau;KentKwoh (Presentedby:JoshuaFarber,MD) CASEOFTHEDAY: (Presentedby:StacyE.Smith,MD;WilliamDocken,MD) 10:05a.m.–10:30a.m. Break–VisitExhibitHall 10:30a.m.–12:30p.m. TUMORSESSIONI Moderators:MarkMurphey,MD;NaveenSubhas,MD 10:30a.m. #18 DiagnosticaccuracyofNaFPETMRIindifferentiatingbonemetastasesfrombenignbone lesionsinmetastaticprostatecancer TaylorJ.Stone;LuisS.Beltran (Presentedby:TaylorStone,MD) 10:50a.m. #19 MRIfeaturesofperipheraltraumaticneuromas ShivaniAhlawat;AllanJ.Belzberg;ElizabethMontgomery;LauraM.Fayad (Presentedby:ShivaniAhlawat,MD) 11:10a.m. #20 Bestpractices:AreprecontrastT1fatsuppressionsequencesnecessaryinmusculoskeletal radiologyclinicalimaging? CarolL.Andrews;SaraK.Golla;DanielA.Smith;AndrewS.Wilmot;KimberlyA.Leeman;Patrick W.Aldred (Presentedby:CarolAndrews,MD) 11:30a.m. #21 IMAGINGOFMUSCULOSKELETALEXTRAPLEURALSOLTARYFIBROUSTUMORWITH PATHOLOGICCORRELATION MatthewMinn;MarkMurphey;MaryKlassenFischer;MarkKransdorf (Presentedby:MatthewMinn,MD) 11:45a.m. #22 ImagingFeaturesofSynovialHemangioma CristyN.Gustas;EricA.Walker;ChikaLogie;DonaldJ.Flemming;MarkD.Murphey (Presentedby:CristyGustas,MD) 12:00p.m. #23 IMAGINGOFDIFFUSETYPEGIANTCELLTUMOROFTENDONSHEATHWITHPATHOLOGIC CORRELATION LienSenchak;MatthewMinn;MaryKlassenFischer;AndrewSonin;MarkKransdorf (Presentedby:LienSenchak,MD) 12:15p.m. #24 IMAGINGFEATURESOFSYNOVIALCHONDROMATOSISVERSUSCPPDDISEASEOFTHE TEMPOROMANDIBULARJOINTWITHPATHOLOGICCORRELATION MarkMurphey;MatthewMinn;MaryKlassenFischer;MarkKransdorf (Presentedby:MarkMurphey,MD) 12:30p.m.–12:35p.m. CASEOFTHEDAY (Presentedby:NicholasM.Beckmann,MD;ManickamKumaravel,MD) 34 Monday, March 9, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 1:00p.m.–3:00p.m. 1:00p.m1:20p.m. 1:20p.m.3:00p.m. *MusculoskeletalUltrasoundHandsOnWorkshop:Elbow Organizer:YoavMorag,MD *SeparateRegistrationRequired–Boxedlunchprovided ElbowUSTheodoreMiller,MD HandsOnWorkshop InstructorsOrganizers: YoavMorag,MDUniversityofMichiganMedicalCenter,AnnArbor,MI Instructors: MaryM.Chiavaras,MD,PhD–McMasterUniversity,Ancaster,ON,CAN JosephG.Craig,MBChB–HenryFordHospital,Detroit,MI GinaA.DiPrimio,MD–TheOttawaHospital,Ottawa,ON,CAN GandikotaGirish,MD–UniversityofMichigan,AnnArbor,MI KatrinaN.Glazebrook,MD–MayoClinic,Rochester,MN JonJacobson,MD–UniversityofMichigan,AnnArbor,MI DavidM.Melville,MD–UniversityofArizonaMedicalCenter,Tucson,AZ TheodoreMiller,MD–HospitalforSpecialSurgery,Mamaroneck,NY KambizMotamedi,MD–UCLA,LosAngeles,CA AkiraM.Murakami,MD–BostonUniversitySchoolofMedicine,Boston,MA Tito(Humberto)Rosas,MDUniversityofWisconsin,Madison,WI MihraTalijanovic,MD–UniversityofArizona,Tucson,AZ CorrieM.Yablon,MD–UniversityofMichiganMedicalCenter,AnnArbor,MI 6:00p.m.–6:30p.m. 6:30p.m.–9:30p.m. NewMembersReception Location:MummyMountain AnnualBanquet Location:MummyMountain 35 Related ePosters FullePosterAbstractsareonPage165 Knee ePoster#17 INTRAARTICULARPATHOLOGYASSOCIATEDWITHISOLATEDPOSTERIORCRUCIATELIGAMENT TEARS EzekielE.Shotts;MarkS.Collins;MichaelD.Ringler;B.MatthewHowe MayoClinicRochester ePoster#18 MEDIALMENISCALPROTRUSIONETIOLOGY:DEEPMEDIALCOLLATERALLIGAMENT INSUFFICIENCYISMORESTRONGLYASSOCIATEDTHANROOTLIGAMENTINJURY PaulWeatherall,MinaHanna,LoweryReiland,GinaCho,HythemOmar,BrianCox,DanMoore UTSouthwestern TumorI ePoster#19 LYTICVSSCLEROTICBONELESIONS:DIAGNOSTICACCURACYOFCTGUIDEDCOREVSFNA BIOPSY TECHNIQUES JadChamieh;WalterCarpenter;BinduAvutu;DouglasRobertson;AparnaKakarla EmoryUniversity ePoster#20 ePoster#21 UTILITYOFDUALENERGYCTVIRTUALNONCALCIUM(DECTVNCA)TECHNIQUEIN MUSCULOSKELETALIMAGINGINTHEACUTEANDSUBACUTESETTING GavinMcKenzie;KatrinaGlazebrook;ErinMoran;ShuaiLeng;CynthiaMcCollough MayoClinicRochester ePoster#22 REDUCERADIATIONDOSEONLUMBARSPINECTUSINGLEANPRINCIPLES ByronY.Chen;StevenJ.Baccei;ChristopherCerniglia UMASSMemorialMedicalCenter ePoster#23 SODIUMFLUORIDEPET/CT:POTENTIALSANDPITFALLSFORMUSCULOSKELETALRADIOLOGISTS BehrangAmini;UsamaSalem;EricM.Rohren MDAndersonCancerCenter ePoster#24 BONEANDSOFTTISSUE"TUMORMIMICKERS":IT'SNOTALWAYSNEOPLASTICDISEASE! Jordan Gross; Michelle McNee; Benjamin Levine; Benjamin Plotkin; Kambiz Motamedi; Leanne Seeger UCLAHealthSystem ePoster#25 PEARLSANDPITFALLSOFNAFPETMRIINTHEEVALUATIONOFPROSTATECANCERPATIENTS FOROSSEOUSMETASTATICDISEASE TaylorJ.Stone;LuisS.Beltran NewYorkUniversityLagoneMedicalCenter ePoster#26 NOTHINGGOODHAPPENSINTHEFIBULA:IMAGINGDIFFERENTIALOFFIBULARTUMORS ScottSchiffman;ValeriyKheyfits;GregoryDieudonne;JohnnyMonu;XiWang UniversityofRochester AREVIEWOFSOFTTISSUELESIONSTHATFREQUENTLYDEMONSTRATELOWT1ANDT2 WEIGHTEDSIGNALONMAGNETICRESONANCEIMAGING JonellePetscavageThomas;EricA.Walker;SangeetaChaudhary;MattMinn;MarkMurphy HersheyMedicalCenter;AIRP 36 Related ePosters FullePosterAbstractsareonPage165 ePoster#27 WORKSTATIONBASEDCTRECONSTRUCTIONFORTHEDETECTIONOFVERTEBRALBODY COMPRESSIONFRACTURES:WHATAREWEMISSING? KevinPreston;JosephBestic;HilliaryGarner;JeffreyPeterson;DanielWessell MayoClinicJacksonville ePoster#28 MRICHARACTERISTICSOFINTRANEURALSYNOVIALSARCOMA UsamaSalem;BehrangAmini;JeanneM.Meis MDAndersonCancerCenter 37 Podium #10 MUSCULOSKELETALRADIOLOGYRESIDENCYCOREANDADAVNCEDELECTIVES:ANEEDSASSESSMENT CorrieM.Yablon,MD;TheodoreT.Miller,MD;BrianPetersen,MD;DonaldJ.Flemming,MD UniversityofMichigan (Presentedby:CorrieM.Yablon,MD) Purpose:Toassessmusculoskeletal(MSK)corerotationsandadvancedelectivesinU.S.residenciesaswellasprogramdirector(PD) attitudes,inordertostructureguidelinesforcompetencybasedtrainingforMSKimaging. Methods:A27questionIRBexempt,anonymoussurveywaselectronicallysenttoprogramdirectors(PD’s)ofACGMEaccredited radiologyresidencyprogramsthroughtheAPDR(AssociationofProgramDirectorsinRadiology).Multiplechoice,yesorno,andfive point Likerttype questions asked about residency program staffing, MSK core and advanced elective rotations, and case volume, includingradiographs,crosssectional(MRI,CTandUS)andinterventionalprocedures.Qualitativequestionsandfreetextresponses weresolicited. Results:82/187(44%)radiologyresidencyprogramresponded.Mostprograms(87.7%)had17MSKtrainedradiologistsandmost (41.3%)had1328residents.Themajorityofprograms(57.5%)offeredanMSKfellowship;93%offeredbetween14positions.82.7% of respondents offered advanced 4th year concentrations in MSK, the majority (58.8%) offering 3 months of MSK electives. Most residencies(55.9%)offered812weeksofMSKcorerotations,most(38%)allowing3residentsmaximumpermonth.Mostprograms (37.7%)interpreted151250MSKradiographs,21150crosssectionalexams,andperformed25jointinjectionsperday,withresidents dictating2040MSKradiographs,610crosssectionalexamsandoneinjectionperday.Spineinjectionswereperformedby27.5%of programs,withonly36.6%havingresidentsparticipate.Mostprograms(68.6%)performeddiagnosticMSKultrasound,and67.9%had residentsdo110MSKUSstudiesperMSKrotation.Mostprograms(65.7%)performedimageguidedboneandsofttissuebiopsy,but 41.4%didnothaveresidentparticipation.PD’sbelievedthat91%oftheirgraduatesarecompetenttointerpretMSKradiographsin anypractice.89.4%thoughtgraduatescouldinterpretcrosssectionalMSKstudiesinageneralpractice,butonly47.7%thoughttheir graduatescouldinterpretthesestudiesinasubspecialtyradiologypractice.58.2%thoughttheirgraduateswerecompetenttoperform arthrographyinpractice.However,only30.8%thoughttheirgraduatescouldperformimageguidedMSKbiopsy;19.7%believedtheir graduatescouldperformspineinjections,and14.9%thoughttheirgraduatescouldperformandinterpretMSKUS.MostPD’s(72.3%) thoughtMSKfellowshiptrainingiscrucialtoeffectivelyperformMSKradiologyandintervention,and69.2%thoughtthatconsensus guidelinesforminimalMSKradiologyexposureduringresidencywouldbehelpful. Conclusion: Although residency programs are starting to offer advanced elective time in MSK, this experience does not provide sufficienttrainingtoallowagraduatetoperformattheMSKsubspecialistlevelinpractice.Therewasnocorrelationbetweenprogram studyvolumesandPD’sperceptionsoftrainees’preparednesstointerpretMSKstudiesinpractice.MostPD’swouldbereceptiveto MSKguidelinesforresidency. 38 Podium #11 MAGNETICRESONANCEIMAGING(MRI)INTHEDIAGNOSISANDMANAGEMENTOFINTERNALDERANGEMENTOFTHEKNEE: DEVELOPMENTOFANEVIDENCEBASEDPREDICTIONMODEL NaveenSubhas;NancyObuchowski;AlexBenedick;AnnaDiStaulo;AmitGupta;MorganJones ClevelandClinic (Presentedby:NaveenSubhas) Purpose:Itisknownfrompreviouslypublishedpilotdatathatonly25%ofmagneticresonanceimaging(MRI)examinationsordered forinternalderangementofthekneeresultinthechangeinpatientmanagement.Thepurposeofthisstudywastodevelopastatistical modelbasedonindividualpatientcharacteristics(e.g.history,symptoms,physicalexamfindings,radiographicfindings,andsuspected diagnosis)tobeabletobetterpredictinwhomakneeMRIwillaltertheclinicalmanagement. MaterialsandMethods:PreMRIandpostMRIsurveyswereprospectivelycompletedbyorthopedicspecialistsin598patientsin whomakneeMRIwasbeingorderedforinternalderangement.PreMRIsurveysrecordedpertinenthistory,symptoms,physicalexam findings,primarydiagnosisandplannedmanagement.PostMRIsurveysrecordedprimarydiagnosisandplannedmanagement.Two thirdsofthepatients(n=402)wererandomlyselectedtobuildthemodel.Themostimportantpredictorsofmanagementchange wereidentifiedusingCART(ClassificationandRegressionTree)andunivariateanalyses.Thesepredictorswerethenusedtocreate thebestfittingmultivariablemodeltakingintoaccountanysignificanttwowayinteractions.Thediscriminatoryabilityofthemodel wasmeasuredusingacindexwith95%confidenceintervals(CI). Results:Patientsinthemodelhadameanageof44.8years(SD16.7)andwere49%female.35%(n=141)hadachangeinmanagement betweensurgery,nonsurgicaltreatmentandnotreatment.84patientschangedfromnonsurgicaltreatmenttosurgery,45patients changedfromsurgerytononsurgicaltreatment,11patientschangedfromeithersurgeryornonsurgicaltreatmenttonotreatment and1patientchangedfromnotreatmenttononsurgicaltreatment.PatientswithapreMRIdiagnosisofnoabnormality,fracture,or LCLtearwere<20%likelytohaveamajorchangeinmanagement,whilepatientswithapreMRIdiagnosisofanACLorMCLtearwere >40%likelytohaveamajorchangeinmanagement.Theonlyvariablethatwasstatisticallysignificantintheunivariateanalysiswas catching(p=0.008).ThestrongestpredictorsintheCARTanalysisweredurationofcomplaint,catching,age,gender,lateraljointline pain,bucklingandMcMurraysign.Thebestfittingmodeltopredictachangeinmanagementwereage<55years,absenceofbuckling, catching,negativeMcMurraysignandapreMRIdiagnosisofameniscalorligamenttear.Theabsenceofbucklingandanegative McMurraysignincreasedthelikelihoodofnochangeinpatientmanagement,whiletheabsenceofbucklingandnopreMRIdiagnosis ofameniscalorligamenttearincreasedthelikelihoodofachangeinmanagement.Thecindexforthismodelwas0.694[95%CIof 0.639,0.747]whichissignificantlybetteratpredictingwhetheranMRIwillchangemanagementthanwithoutuseofthemodel. Conclusions: Using an evidencebased statistical model based on individual patient characteristics when ordering a knee MRI in patientswithinternalderangementwillimprovetheorderingclinician’sabilitytopredictwhentheMRIwillalterpatientmanagement. 39 Podium #12 BASELINECARTILAGETHICKNESSANDMENISCUSEXTRUSIONPREDICTLONGITUDINALCARTILAGELOSSBYQUANTITATIVEMRI: DATAFROMTHEOAI JasonKlein;JeanJose;MichaelBaraga;TySubhawong UniversityofMiamiMillerSchoolofMedicine (Presentedby:JasonKlein) BACKGROUND:Jointspacenarrowingonplainradiographshaslongbeenusedasaproxyforthedegreeofkneeosteoarthritis(OA). Morerecently,theutilityofdifferentquantitativeMRI(qMRI)techniquesmeasurementsofcartilagemorphologyhavebeenshown tobemoreresponsivetokneeOAprogression. OBJECTIVE:ToevaluatehowdemographicvariablesandmeniscusdamageinfluencethedegreeofcartilagelossassessedbyqMRI longitudinally,andwhethercartilagelosscorrelateswithpainoutcomescores. METHODS:Of4,796participantsintheOsteoarthritisInitiative(OAI),asubsetof86hadbaselineand48monthfollowupqMRImedial femorotibialcartilagethicknessdataandwereincludedinthestudy.The86subjectshadameanageof59.9years(range4579years), were48%male,andhadmeanbaselineBMI29.7(range1846).Othervariablesincludedbaselinemeniscuspathology,andKneeInjury andOsteoarthritisOutcomeScore(KOOS)Outcomesmeasures(baselineand72months).Amusculoskeletalradiologistevaluated meniscuspathologyonbaselineMRIs;menisciwereassignedWholeOrganMagneticResonanceImagingScore(WORMS)scores,and gradedondegreeofmeniscalextrusiononeachkneeincludedinthestudy. RESULTS:Meancartilagelossforthe86subjectcohortwas0.074mm(range0.08to0.43mm,p<0.0001,pairedttest).Cartilageloss correlated poorly with age (Pearson r=0.24) and had no association with gender (male mean 0.085, female mean 0.063, p=0.27, Wilcoxonranksum).BaselineWORMSscore,whendichotomizedto2(n=44)and>3(n=42),wasfoundtobeasignificantpredictor oflongitudindalcartilageloss(p=0.04Wilcoxonranksum).Furthermore,meniscusextrusiongradedasabsent(n=51),<50%(n=28), and>50%(n=7)correlatedwithmeancartilagelosses0.02,0.159,and0.126mm,respectively(p=0.0001,KruskalWallis).Multivariable regression analysis with cartilage volume as the primary outcome showed that baseline cartilage thickness (adjusted regression coefficient=0.051,95%CI:0.087,0.014)andmeniscalextrusion(adjustedregressioncoefficient=0.115,95%CI:0.0690.160)were theonlysignificantpredictorsoffuturecartilageloss(p=0.008andp<0.001,respectively).Age,sex,BMI,anddichotomizedWORMS scoreswerenotsignificantatalpha=0.05.Theregressionmodelwassignificant(p<0.001,R^2=0.44).ChangesinKOOSpainscores didnotcorrelatewithqMRIcartilageloss(Pearsonr=0.018). CONCLUSION:Baselinecartilagethicknessandmeniscusextrusionareimportantandindependentpredictorsforacceleratedcartilage lossanddevelopmentofworseningosteoarthritis.However,thedegreeofcartilagelossdidnotcorrelatewithlongertermchangein clinicaloutcomescores,whichhighlightsthecomplexitythatdrivessymptomatologyinosteoarthritis. 40 Podium #13 SUBCHONDRALINSUFFICIENCYFRACTUREOFTHEKNEE:REVISINGTHEEPIDEMIOLOGYANDSOFTTISSUEEDEMAPATTERN AndrewWilmot;Alexruutiainen HospitalofUniversityofPennsylvania (Presentedby:AndrewWilmot) Objectives:SONK(spontaneousosteonecrosisoftheknee),firstdescribedin1968,remainsanincompletelyunderstoodclinicalentity thatresultsfromsubchondralinsufficiencyfractureoftheknee(SIFK).Itisdescribedasadiseaseoftypicallyelderlywomeninthe6 7thdecadeoflife.Sincewehadtheimpressionthatweseethisdiseaseofteninmales,wesetouttofurtherelucidatetheepidemiology ofSIFK,itsrelationshipwithmeniscalpathologyandsofttissueedemapatterns,andtoassessMRimagingcharacteristicsthatpredict progression.SincesofttissueedemainSIFKisoftenseebuthasnotyetbeendescribed,thesecondpurposeofthisstudywasto evaluatethefrequencyandpatternofthesofttissueedemainSIFK. Methods:MRIswereretrospectivelyreviewedfor77patientswithatotalof80SIFKs.Caseswerereviewedforinsufficiencyfracture, meniscaltear,meniscalextrusion,andsofttissueedemapattern.Theclinicalrecordwasreviewedforage,gender,andBMI.Statistical analysiswasperformedtoassesseachnonparametricimagingfindingasapredictorofSIFKlocation. Results:SIFKshadanequalincidenceinmalesandfemales(M:F=40:37).Itwasmostcommoninpatientsinthe6thand7thdecades (mean:61years,range:3789).SIFKwassignificantlymorecommonintheMFC(63%,²p<0.01),followedbyLFCin19%(15/80), MTPin15%(12/80),andLTPin4%(3/80).Edemainthesofttissueswasdemonstratedin91%(70/77).Thesofttissueedemapattern was:posteriorpoplitealfossa(100%),abuttingtheposteriordistalfemoralcortex(65%),extendingtothevastusmedialisandvastus lateralis fascia (49%, 27% respectively), abutting the MCL (75%), and abutting the medial tibial plateau (17%). Joint effusion was presentin51%andsynovitisin48%ofcases.SofttissueedemapatternswerepredictiveofSIFKlocation.Medialmeniscaltearwas present in 73% of medial SIFKs, and, in cases where imaging follow up was available, meniscal extrusion was associated with progressionofosteoarthritis. Conclusion:Insufficiencyfractureofthekneeaffectsmalesandfemalesequally,unlikepriorstudies.Theyareusuallyseeninthe6 7thdecadebutcanbeseenatamuchyoungerage.Softtissueedemaintheposteriorpoplitealfossaisseeninalmostallpatientsand the soft tissue edema patterns may correlate with the location of SIFK. Meniscal extrusion was associated with progression of osteoarthritis. 41 Podium #14 MAGNETICRESONANCEIMAGINGOFPOPLITEALDEEPVENOUSTHROMBOSISONROUTINEIMAGINGASSESSMENTOFTHEKNEE LawrenceWhite;RyanShulman;CraigBuchan;RobertBleakney UniversityofToronto (Presentedby:LawrenceWhite,MD) Purpose:ToinvestigatetheMRIfeaturesofpoplitealvein(PopV)deepvenousthrombosis(DVT)onroutineMRIassessmentofthe kneejoint. Materials&Methods:FollowingIRBapproval,andwaivedconsent,retrospectivereviewof2894consecutivekneeMRIexaminations, acquiredatonehospitalsitebetweenJanuary2011andJuly2011wasperformed.Sixcaseswereexcludedfromstudyevaluation;3 withhistoryofcarcinoma,and3withhistoryofsolidpoplitealmasslesions.AllMRimagingwasperformedona1.5T,or3T(Siemens AG)system,utilizingmultichannelkneecoils.AroutinekneeMRIprotocolwasperformedinallcases,including;axialT2weightedfat saturatedfastspinecho(FSE),sagittalintermediateweightedandT2weightedfatsaturatedFSE,andcoronalintermediateweighted FSE acquisitions. All studies were reviewed in consensus by 2 Musculoskeletal radiologists. Each examination was classified as illustratingeitheranormalappearancetothepoplitealvein(PopV);characterizedbynormalvenousluminalflowwithperipherallow signal intensity flow void and homogeneous central high signal, +/ intermixed signal attributable to venous inflow; or findings suspicious for popliteal DVT characterized by heterogeneous central and peripheral intraluminal signal intensity, and/or a well marginatedintraluminalheterogeneousfillingdefect.AllcasessuspiciousforpoplitealDVT,wereadditionallyevaluatedforpresence or absence of; PopV dilation, PopV wall thickening, intramuscular signal changes, and adjacent perifascial, subcutaneous, and perivascular edema. Clinical chart review was performed in all cases to identify cases in which lower extremity Doppler venous ultrasound,orcomputedtomographicpulmonaryangiography(CTPA)studieswereperformedwithin1weekofMRIexaminationof theknee. Results:2879/2888(99.69%)kneeMRIexamsshowedanormalappearancetothePopV.Fiveofthesecases(5/2879)haddoppler ultrasoundexamsperformedwithin1weekofMRI,noneofwhichshowedevidenceofDVT.Nine(9/2888,0.31%)kneeMRIexams illustratedfindingssuspiciousforpoplitealDVT.Inthese9cases;perifascialedemawasseeninallstudies(9/9,100%),venousdilation, increased intramuscular T2weighted signal, and subcutaneous and perivascular edema were seen in all but one case each (8/9, 88.89%),andPopVwallthickeningwasobservedintwocases(2/9,22.22%).FourofthecasessuspiciousforPopVthrombosisonMRI (4/9)hadvascularimagingperformedwithin1weekofMRI;3venousDopplerultrasoundexaminationspositiveforPopVDVT,1CTPA demonstratinganacutepulmonaryembolus.AnadditionalfourcasessuspiciousforPopVthrombosisonMRI(4/9),alsohadpositive DopplerultrasounddocumentationofPopVDVT.However,Dopplerultrasoundexaminationineachofthesecaseswasperformed morethan1week,precedingorfollowingtheirreferenceMRIexam Conclusion:TheincidenceofpoplitealDVTinourpatientcohortreferredforkneeMRimagingwasapproximately0.3%.Thepopliteal veinshouldberoutinelyinterrogatedforabnormalfillingdefects,heterogeneousintraluminalsignal,andsupportinglocalancillary findingsofPopVthrombosisinpatientsreferredforMRIevaluationofkneejointderangement. 42 Podium #15 MASSLIKESTRUCTUREINTHEINTERCONDYLARNOTCH:“PSEUDOLESION”ORASENTINELLESION? TetyanaGorbachova;MinnSaing;RyanSmith;IgorGoykhman EinsteinMedicalCenter (Presentedby:TetyanaGorbachova) Background:ContentsoftheintercondylarnotchareeasilyidentifiableonMRIexaminationofthekneeandincludecruciateligaments, smallvessels,andmeniscofemoralligamentsoutlinedbyfat.Signalalterationinthisareacanbeviewedaspathologicandraises considerationofalocalizednodularsynovitis,intraarticularbody,oradisplacedmeniscalfragment.Weencounteredasmallseriesof patientssharingasimilarfindingofamasslikeintermediatetolowsignalintensityabnormalityonallpulsesequencesseeninthe medialaspectofintercondylarnotch.Weattempttohypothesizeitsnatureandclinicalsignificance. MaterialsandMethods:Weretrospectivelyevaluated13kneeMRIswithovoidintermediateorlowsignalintensitystructureinthe intercondylarnotchabuttingthelateralaspectofthemedialfemoralcondyle(MFC).Patients’demographics,presenceofLigamentof Humphry,statusofACLandPCL,adjacentcartilageatthelateralaspectoftheMFCaswellasthepresenceofsynovitiswereevaluated. Arthroscopicimageswereretrospectivelyreviewedin3patients. Results:Allpatientsweremale,agerangeof1365yrs,mean27.1yrs.LigamentofHumphrywaspresentonMRin77%(10/13).ACL tearwasseenin4patients(3completeand1partialthicknessestear).AdjacentMFCcartilageabnormalitieswereseenin69%(9/13), andincludedclassicjuvenileosteochondritisdissecans(OCD)(3/9),heterogeneouscartilagesignal(2/9),andheterogeneoussignal andfissuring(4/9).AllpatientswithcartilageabnormalitieshadintactACLs,withtheexceptionof1caseofpartialthicknessACLtear inapatientwhoalsohadahealedOCD.Arthroscopicfindingswereavailablein3patients:2performedforACLreconstruction,1 performedtoevaluateforlocalizednodularsynovitis.In2patients,whounderwentACLreconstruction,nopathologicfindingswere foundtoaccountfortheglobularsignalinthenotch,whileaprominentligamentofHumphrywasnoted.Inonepatientinwhomthe signalchangesintheintercondylarnotchweretheonlyabnormalityonMRI,thisareawasfoundtorepresentscarringandsynovitis onarthroscopy;additionally,anadjacentdelaminatingchondraldefectwasfoundintheMFC,whichwasretrospectivelyidentifiedon MRI. Conclusion:Amasslikeareaofsignalalterationinthemedialaspectoftheintercondylarnotchcanbeseenin2mainsubsetsof patients. Inpatients with anACL tear, this signal change likely represents a physiologic finding when the masslike appearanceis mimickedbyalaxligamentofHumphry,asseeninextendedkneepositiononMRI,andexaggeratedbyananteriortibialtranslation inanACLdeficientknee.InpatientswithoutanACLtear,asignalabnormalityofthenotchisfrequentlyaccompaniedbyanadjacent cartilagelesionofmedialfemoralcondyle,andmayrepresentasentinelsynovitisoccurringsimultaneouslyorinresponsetoacartilage damage.Thepresenceofmasslikesignalchangesinthemedialaspectoftheintercondylarnotchshouldpromptcarefulevaluation ofadjacentMFCcartilageforsubtlelesions. 43 44 45 Podium #16 COMPARINGANACCELERATED3DFASTSPINECHOSEQUENCEUSINGCOMPRESSEDSENSING(CSSPACE)FORKNEEMAGNETIC RESONANCEIMAGING(MRI)WITHTRADITIONAL3DFASTSPINECHO(SPACE)ANDROUTINE2DSEQUENCES FaysalAltahawi;NicholasMorley;KevinBlount;ImranOmar NorthwesternUniversityFeinbergSchoolofMedicine (Presentedby:FaysalAltahawi) Purpose: 3D fast spin echo (FSE) MRI offers potential improvements upon 2D MRI traditionally used in musculoskeletal imaging, includingimprovedspatialresolutionandmultiplanarreconstructions(MPRs).However,incorporationofcurrentlyavailable3DFSE sequences into practice has been limited by longer scan times and uncertain diagnostic benefit when compared to routine 2D acquisitions.Wecompareanewaccelerated3DFSEacquisitiontechniquethatutilizescompressedsensingtotraditional2Dand3D acquisitions. MaterialsandMethods:AfterIRBapprovalandinformedconsent,20patientsreceivedkneeMRIsthatincludedroutine2D(T1,PD FS,andT2FS;0.5x0.5x3mm3;25min),traditional3DFSE(SPACEFS;0.5x0.5x0.5mm3;7min),andcompressedsensingaccelerated 3DFSE(CSSPACEFS;0.5x0.5x0.5mm3;5min;EstherMeyer)acquisitionsona3TMRIsystem(SiemensSkyra).Threefellowshiptrained musculoskeletalradiologists(MSKRs)independentlyassessedthestudieswithgradedsurveysofimageandtissuespecificdiagnostic quality.Tissuespecificsignalintensities,signaltonoiseratios(SNR),andcontrasttonoiseratios(CNR)weremeasuredwithconsistent regionsofinterest.TwotailedstudentsTtestsandchisquaredanalyseswereusedforstatisticalcomparison. Results:Forassesseddiagnosticquality,CSSPACEwassignificantlybetterforevaluationofcartilagethanSPACEand2Dsequences (P<0.001).CSSPACEwassignificantlybetterthanSPACEandnotstatisticallydifferentthan2Dsequencesforevaluationofmenisci (P<0.001andP=0.347,respectively)andsynovialfluid(P<0.001andP=0.321,respectively).BothCSSPACEandSPACEwerebetter than2Dsequencesforevaluationofbloodvessels(P<0.001).CSSPACEwasnotsignificantlydifferentthanSPACEandsignificantly worsethan2Dsequencesforevaluationofbones(P=0.167andP<0.001,respectively),ligaments(P=0.095andP<0.001respectively), muscles(P=0.901andP<0.001,respectively),andfat(P=0.057andP=0.004,respectively).Forassessedimagequality,CSSPACEand SPACEhadhigherspatialresolution(P<0.001),butlowercontrast(P<0.001).CSSPACEhadmorenoisethanSPACE(P=0.004)and2D sequences(P<0.001).TheoverallimagequalityfromCSSPACEwasassessedasbetterthanSPACE(P=0.007),butworsethantraditional 2Dsequences(P<0.001).ComparedtoSPACE,CSSPACEhashigherfluidsignalintensity(P<0.001),SNR(P<0.001),andCNRagainstall othertissues(allP<0.001). Conclusion:Anewaccelerated3DFSEtechniqueutilizingcompressedsensing(CSSPACE)allowsforfasterisotropicacquisitionsof kneeMRIsovercurrentlyusedprotocols.ImprovedfluidandcartilageCNRovertraditional3DFSEacquisitionsandhigherspatial resolutionoverroutine2DsequencesmaypresentavaluableroleforCSSPACEintheevaluationofcartilageandmenisciwithpotential forMPRs. 46 Podium #17 EARLYBONECURVATURECHANGESOFTHEKNEEDETECTEDONMRICANPREDICTOAPROGRESSION:DATAFROMTHEOAI JoshuaM.Farber;JoseTamezPena;DavidHunter;MichaelHannon;SaaraTotterman;ZhijieWang;RobertBoudreau;KentKwoh RadiologyAssociatesofNorthernKentucky (Presentedby:JoshuaM.Farber,MD) Purpose: In the knee, osteoarthritis (OA) involves changes in the articular cartilage (AC), menisci and bone shape, particularly subchondral, articulating bone surfaces. These changes result ultimately in joint space narrowing, which can be measured with radiographsandtheKLscoringsystem.EndstageOAresultsinboneonbonearticulationandtotalkneereplacement(TKR).Thisstudy investigates the association of early bone curvature changes detected on MRI and the subsequent development of radiographic evidentOA(incidentOA)andtheneedforTKR(endstageOA). Methods: Case and control pairs were selected from 4,796 participants from the Osteoarthritis Initiative (OAI), a multicenter populationbasedcohortstudydesignedtoidentifybiomarkersofkneeOAdevelopmentand/orprogression.Incidentcases(n=289) were defined by a change from KL0/1 to KL>2. Endstage cases (n=119) were participants who received a TKR, confirmed by radiographyand/orareviewofhospitalrecords.MatchedcontrolswereselectedwiththesameKL,sexandagewithin5years.Time pointsincludedthedefiningevent(TO),whereincidentOAwasfoundoraTKRperformed,andavailableprecedingtimepoints.OAI 3DWEDESSsagittalimages(Siemens)wereusedforcurvaturemeasurementsateachtimepoint.Measurementsfortotalandsub regional articulating bone surfaces were obtained using segmentation software (CiPAS, Qmetrics). Longitudinal KL scores were obtainedaswell.Meanandstandarddeviationofcurvatureandjointspacelongitudinalmeasurementsforcaseandcontrolcohorts were analyzed using a generalized estimating equation model (SAS: GENMOD) to account for the interdependence between longitudinaloutcomes. Results: There were statistically significant differences (p<0.05) between case and control pairs for incident and endstage OA. Statisticallysignificantdifferenceswereseenintheincidentgroupfortheentirefemurandforthecentral,weightbearingmedialand lateralfemurmeasurements(Fig1).Ingeneral,incidentkneeshadlesscurvatureatbaselineandflattenedatagreaterratethandid controlknees.ForendstageOA,therewerestatisticallysignificantdifferencesforthewholefemurandforthecentralmedialfemoral condyle. Conclusion:Inthisstudy,subjectswhodevelopedincidentOAhadcurvaturechangesdetectedonMRIsignificantlydifferentfromthe matchedcontrolgroup,evenwhenbothgroupshadradiographicKLscoresofzero.Similarly,thosekneeswhichdevelopedendstage OAhadMRIdetectablecurvaturedifferences,statisticallysignificant,thandidthematchedcontrolknees.Inboththeincidentand endstagegroups,theeffectedkneeschangedshapeovertimemorequicklythandidthematchedcontrols,ingeneralbecomingmore flattened.Thefemursdemonstratedgreaterplasticitythanthetibiasinboththeincidentandendstagegroupsovertime.Thusbone curvaturebiomarkerdevelopmentforOAmaybemorefruitfulbyfocusingonthefemurratherthanthetibia.Finally,earlychanges wereseenwithMRIincasesofKL=0,suggestingaroleforMRIinearlyscreening. Sponsor:NIHHHSN268201000021CPivotalOAIMRIAnalyses(POMA) 47 Podium #18 DIAGNOSTICACCURACYOFNAFPETMRIINDIFFERENTIATINGBONEMETASTASESFROMBENIGNBONELESIONSINMETASTATIC PROSTATECANCER TaylorJ.Stone;LuisS.Beltran NYULangoneMedicalCenter (Presentedby:TaylorJ.Stone) Purpose:ToevaluatethediagnosticaccuracyofNaFPETMRIindifferentiatingbonemetastasesfrombenignbonelesions,suchas degenerativechanges,inpatientswithmetastaticprostatecancer. MaterialsandMethods:11patientswithprostatecancerandbonemetastasesunderwentNaFPETMRI.TheMRIincludedanatomic T1/T2/STIRsequencesaswellasdiffusionweightedimaging(DWI)usingbvaluesof50and800.Eachbonelesionwastabulatedas benignormetastaticforeachimagetypeusingeitherNaFPETMRI,NaFPETCT,orbiopsyasthegoldstandard.Bonescintigraphywas availablein7ofthe11patientsandreadindependentlywithoutknowledgeofthePETMRresults.SUVmaxonPETandADCmin,mean, maxonDWIwasmeasuredforeachlesion.Mixedmodelanalysisofvariance(ANOVA)wasusedtocomparebenignandmalignant lesionsintermsofeachmeasure.Specificity,sensitivity,andoverallaccuracyfordiscriminationofbenignandmalignantlesionsusing eachmodality(BS,PET,DWI,PET/MRI)werecalculated.AreaundertheROCcurve(AUC)achievedbyeachmeasure,thresholdto definelesionsastestpositiveformalignancythatmaximizedtheaveragesensitivityandspecificity,andsensitivityandspecificity achievedattheindicatedthresholdwerecalculated. Results: 36 total bone lesions were evaluated, including 21 metastases and 15 benign lesions. ADCmean was significantly lower (p=0.008)andSUVmaxsignificantlyhigher(p=0.024)amongmalignantlesionsthanbenignlesions.Nosignificantdifferencebetween malignantandbenignlesionswasseenwithADCmin(p=0.09)andADCmax(p=0.140).Specificity,sensitivity,andoverallaccuracyof eachmodalitywas:100%,31%,65%forBS;53%,86%,72%forDWI;13%,100%,64%forPET;100%,86%,92%forPET/MRI.AUC, threshold,andachievedsensitivityandspecificityatthatthresholdforeachparameterwas:0.7,>17.95,62%,80%forSUVmax;0.67, 1.377, 56%, 87% for ADCmax; 0.8, 0.6224, 67%, 93% for ADCmean; 0.6, 0.221, 82%, 47% for ADCmin. AUC of ADCmin was significantlylowerthanthatofADCmean(p=0.012).TherewerenoothersignificantdifferencesbetweenmeasuresintermsofAUC (p>0.1). Conclusion:NaFPETMRIasahybridimagingstudyshowshigherspecificity,sensitivity,andoverallaccuracythanBSandPETorDWI inisolationindifferentiatingbetweenmetastaticandbenignbonelesions.Accuratelydefiningthenumberoflesionshasimportant treatmentimplicationsasprostatecancertreatmentisgenerallybasedondiseaseburden. 48 Podium #19 MRIFEATURESOFPERIPHERALTRAUMATICNEUROMAS ShivaniAhlawat;AllanJBelzberg;ElizabethMontgomery;LauraMFayad JohnsHopkinsUniversity (Presentedby:ShivaniAhlawat) BACKGROUNDANDPURPOSE:Atraumaticneuromaisadisorganizedmassoffibroneuraltissuethatdevelopsasaresultofafailed attemptatnerveregenerationafteraninjury.Traumaticneuromasaresevereinjuriesofthenervethatdonotallowconductionand areclassifiedintoneuromaincontinuity(NIC)afterpartialnervetransection,orendbulbneuromas(EBN)aftercompletedisruption. Traumaticneuromascanmimicperipheralnervesheathtumors(PNSTs)onimagingandcontrastenhancedsequenceshavebeen suggestedasamethodofdistinguishingthetwoentities.ThepurposeofthisstudyistodescribetheMRIappearanceoftraumatic neuromasonnoncontrastandcontrastenhancedMRIsequences. METHODANDMATERIALS:ThisIRBapproved,HIPAAcompliantstudyretrospectivelyreviewedtwelvesubjectswith20traumatic neuromas.MRIswereevaluatedbytwoobserversforneuromasizeandMRIfeatures(signalintensity,heterogeneity,enhancement, margin,capsule,continuitywithparentnerve,tailsign,targetsign,splitfatsign,anddenervation)onT1weighted(T1),fatsuppressed T2weighted(T2)andcontrastenhancedT1weightedsequences.Descriptivestatisticswerereported.Pearsoncorrelationwasused toexaminetherelationshipbetweenneuromasizeandparentnervecaliber. RESULTS:Of20neuromas,13wereNICand7wereEBN.OnT1,signalintensitywashomogeneouslyisointensetoskeletalmusclefor 100%(20/20)oftheneuromas.OnT2,signalintensitywashyperintensefor100%(20/20)ofneuromas,andheterogeneousfor29% (2/7)EBNand46%(6/13)NIC.Followingcontrastadministration(in8cases),88%(7/8)ofneuromasshowed>75%heterogeneous enhancement, with 12% (1/8) showing no enhancement. All neuromas (20/20) had indistinct margins while none (0/20) had a definablecapsule.Allneuromas(20/20)hadatailsign,and35%(7/20(allEBNs))demonstrateddiscontinuityfromtheparentnerve. None(0/20)showedatargetsign.Thesplitfatsignwaspresentin0%(0/7)ofEBNand8%(1/13)ofNIC.Skeletalmuscledenervation wascommon,identifiedin100%(7/7)ofEBNand69%(9/13)ofNIC.Neuromashadameansizeof1.5cm(range0.64.8cm),and therewasmoderatecorrelation(r=0.68,pvalue=0.001)withthecaliberoftheparentnerve;largerneuromasarosefromlarger parentnerves. CONCLUSION: The MRI features of peripheral traumatic neuromas have been described. Because features include enhancement following contrast administration, intravenous contrast medium cannot be used to distinguish neuromas from PNSTs. The clinical historyofantecedenttraumawiththelackofatargetsignmaybethemostusefulcluestoarrivingattheappropriatediagnosis. 49 Podium #20 BESTPRACTICES:AREPRECONTRASTT1FATSUPPRESSIONSEQUENCESNECESSARYINMUSCULOSKELETALRADIOLOGYCLINICAL IMAGING? CarolL.Andrews;SaraK.Golla;DanielA.Smith;AndrewS.Wilmot;KimberlyA.Leeman;PatrickW.Aldred UniversityofPittsburghMedicalCenter (Presentedby:CarolL.Andrews) Introduction:Thetechniquesoffatsuppressionandcontrastenhancementarecommonlyusedintheevaluationofmusculoskeletal conditions.Ithasbeenarguedthatifastudyistobeacquiredwithgadoliniumcontrast,theimagershouldacquiringT1weightedfat suppressedimagingbothpriortoandaftertheadditionofcontrasttoassistinimprovedconspicuitywhileavoidingpitfallssuchasthe presenceofbloodproductsortherescalingeffectthatmayoccurwithchemicalshiftfatsuppression.Theadditionofprecontrastfat suppressionresultsinincreasedtimeinthescanner(particularlywhenimaginganextremityinashortborescannerwheretwosets of images are needed to adequately interrogate the area of interest), resulting in potential increased patient discomfort and an incompletestudyifthepatientrefusestocompletethestudy,anddecreasedscannerthroughput.Weinvestigatetheutilityofpre contrast T1 fatsuppressed (preT1FS) MR images in the evaluation of four general categories: neoplasms, infection, trauma and arthritis. Methods: This retrospective, IRB approved comparative effectiveness noninferiority study involved the individual evaluation of selectMRcasesbyagroupof3musculoskeletalradiologists,blindedtotheclinicalhistoryandoutcomes.Thecaseswereselected basedonthefollowingcriteria:1)olderthan18;2)nopriorhistoryofsurgerytotheareabeingevaluated;3)definitivediagnosis available.Thereaderswereaskedtodeterminediagnosisandevaluatevariousfeaturesoftheimagedabnormality,characterization ofenhancementandconfidencelevelsinevaluatingsuchfeatures.Somenormalcaseswereincludedinthemixofcases.Twomonths later,thereaderswerepresentedwitharandomsetofthesamecaseswiththeimagingsequencesalteredasfollows.Iftheyhad previouslyseenthecasewiththepreT1FSsequencesremoved,thosesequenceswereaddedback.Ifthosesequenceswerepresent previously,theywereremoved.Thesamesetofquestionswasthenasked. Results:50caseswereevaluatedattwoseparatetimesbythereaders.Twoonesidedttestswereusedfortheequivalenceevaluation. Thediagnosticaccuracyrate(%correctdiagnosisbyselectingcorrectprimaryandsubtypediagnosiscategory)was77%forcases withouttheadditionalpreT1FSwhilethediagnosticaccuracyforthefullsetofsequenceswas45%.Determinationofthepresenceof anabnormality,detectionofcontrastenhancement,reportedusefulnessofcontrastandconfidenceinthesefindingswasstatistically equivalent without the preT1FS sequences. The reader’s confidence in their diagnosis and ability to delineate the abnormality’s relationshiptoadjacentstructures/compartmentswasnotstatisticallydemonstrated,thoughthedatatendedtowardtheimaging withoutthepreT1FSsequence. Conclusion:AbsenceofthepreT1FSsequencedoesnotadverselyaffecttheabilityofMSKradiologisttoproperlyinterpretmostMSK images and make proper diagnosis/assessments. Diagnostic accuracy and most other MRI evaluations variables are statistically equivalentwhenthepreT1FSsequenceisnotincluded. 50 Podium #21 IMAGINGOFMUSCULOSKELETALEXTRAPLEURALSOLTARYFIBROUSTUMORWITHPATHOLOGICCORRELATION MatthewMinn;MarkMurphey;MaryKlassenFischer;MarkKransdorf AmericanInstituteforRadiologicPathology (Presentedby:MatthewMinn) Purpose: To evaluate the imaging appearance of musculoskeletal extrapleural solitary fibrous tumor (ESFT) with pathologic correlation. MaterialsandMethods:Weretrospectivelyreviewedatotalof20patientswithpathologicallyconfirmedmusculoskeletalESFTwith pathologicconfirmation.Radiologicstudieswerereviewedbytwomusculoskeletalradiologistswithagreementbyconsensus.Imaging studies included radiography (n=2), angiography (n=3), ultrasound (n=2), CT (n=12), and MRI (n=17). Evaluation included patient demographics,size,location,presenceofafeedingvascularpedicle,internalvessels,intralesionalfat,neurovascularencasement,and intrinsicfeaturesonCTandMRimaging. Results:Patientagerangedfrom27to65years(average=47)with47%femalesand53%male.Thethigh(n=8)andpelvis(n=8)were most frequently involved, each equally accounting for 40% of the cases followed by the upper extremity (10%; n=2), and lower extremity (10%; n=2). Lesions not within the pelvis were predominately centered intermuscularly (77%; n=10) followed by intramuscular(15%;n=2)andlastlyinthesubcutaneoustissues(8%;n=1).Lesionsizerangedfrom4to20cminmaximaldimension (average=11cm).NoncontrastCTrevealedrelativelyhomogenousattenuationsimilartomuscleonallcasesevaluated(n=12).OnMR, thepredominateT1andT2signalintensitywasisointensetomuscle(95%;n=19)andhyperintensesignal(95%;n=19)withmildto moderateheterogeneity,respectively.USdemonstratedamildlyhypoechoicmasswitharterialandvenousflowvisualizedonDoppler in all cases (n=2). Intense staining with early venous shunting was seen in all cases evaluated with angiography (n=3). Marked heterogeneousenhancementwasseenin95%(n=19)ofcasesonMRand100%ofcasesonCT(n=12).Afeedingvascularpediclewas seenin75%(n=15)ofcasesandintrinsichighflowvesselsin60%(n=12)onMRimaging. Conclusion:ImagingfeaturessuggestiveofmusculoskeletalESFTincludeanintermuscularmassaffectingthethighorpelvismost frequentlywithmarkedheterogeneousenhancement,thepresenceofafeedingvascularpedicleandintralesionalhighflowvessels. Itisimportanttorecognizetheprominentvascularcomponentsbothtosuggestdiagnosisbutalsovitaltohelpplanbiopsyapproach andsurgicalresection. 51 Podium #22 IMAGINGFEATURESOFSYNOVIALHEMANGIOMA CristyN.Gustas;EricA.Walker;ChikaLogie;DonaldJ.Flemming;MarkD.Murphey AmericanInstituteforRadiologicPathology (Presentedby:CristyN.Gustas,MD) Hemangiomasarisingfromthesynoviumareuncommonlyencounteredlesionsand,assuch,mayrepresentaclinicalandimaging diagnosticdilemma.Accurateimagingdiagnosiscanhelpdistinguishtheselesionsfrommorecommonlyencounteredsynoviallybased pathologyandguideappropriatemanagement. AnIRBapprovedretrospectivereviewof21pathologicallyprovensynovialhemangiomaswasperformedinattempttodetermine diagnosticimagingcharacteristicsonvariousimagingmethods.Thesemethodsincludedradiograph(n=19),MRI(n=13),CT(n=4),US (n=3), arthrogram (n=2), or angiogram/MR Angiogram (n=3). Images were reviewed and agreement reached by a consensus interpretationoffiveobservers. Thepatientsrangedinagefrom1to49yearsatthetimeofpresentation(averageage,19years)withaslightmalepredominance (n=14).Themostcommonlyaffectedregionwasthekneejointin85%(n=18)ofcases,followedbytheelbow(n=2)andhand/foot (n=2). Softtissuefullnessorswellingwasseenonradiographsin84%(16/19).Osseouschanges,includinghypertrophy,erosion,remodeling, osteopenia, or periosteal reaction was seen in 31% of cases on radiographic evaluation. Interestingly, only one of the cases with radiographsdemonstratedphleboliths. Forthe13casesevaluatedwithcrosssectionalimaging,alldisplayedalobulatedperiarticularsofttissuemassonMRI(13/13)orCT (4/4).AfewcharacteristicfeaturesonMRIincludedseptations(n=10),feedingvessels(n=11),evidentfatsignal(n=11),centrallow signalintensitydots(n=10),internallowT2signalsuggestiveofthrombus(n=8),andcavernousappearance(n=9).Fluidlevelswere seeninfouroftheninelesionswithacavernousappearance.Intramedullaryfeedingvesselswerenotedin38%(n=5)ofcasesonMRI. TheaforementionedosseouschangeswerenotedinfourcaseswithMRI. ThemassesdemonstratedisointensesignalonTlweightedspinechoimagesinallcasesandheterogeneousbuthyperintensesignal onfluidsensitivesequences.Allofthesynovialhemangiomasenhancedintenselyincaseswherecontrastwasadministered(n=10) andserpentinemorphologywasbetterappreciated.Synovialhemosiderindepositionwasnotedinonecaseandfourcasesdisplayed synovitis.Nocasesdemonstratedacutehemorrhageorhemarthrosis. All of the cases evaluated with ultrasound presented as defined, yet not circumscribed, hypoechoic masses with septations and internalechoes.InternalbloodflowwasnotedonDopplerevaluation. This review represents the largest case series to date evaluate the imaging features of synovial hemangioma. Although no single imaging criteria was diagnostic, analysis of lesion signal and morphology, including serpentine feeding vessels or a cavernous appearance,canhelptoconfidentlyidentifysynovialhemangiomasandultimatelyguidemanagementandavoidbiopsy. 52 Podium #23 IMAGINGOFDIFFUSETYPEGIANTCELLTUMOROFTENDONSHEATHWITHPATHOLOGICCORRELATION LienSenchak;MatthewMinn;MaryKlassenFischer;AndrewSonin;MarkKransdorf AmericanInstituteforRadiologicPathology (Presentedby:LienSenchak) Purpose:Toevaluatetheimagingappearanceofdiffusetypegiantcelltumoroftendonsheathwithpathologiccorrelation. MaterialsandMethods:Weretrospectivelyreviewedatotalof6patientswithpathologicallyconfirmeddiffusetypegiantcelltumor oftendonsheath(GCTTS)withpathologicconfirmation.Radiologicstudieswerereviewedbytwomusculoskeletalradiologistswith agreementbyconsensus.Imagingstudiesincludedradiography(CR)(n=1)andMRimaging(n=6).Evaluationincludeddemographics, lengthoftendoninvolvement,presenceoferosions,andintrinsicfeaturesonMRimaging. Results: Patient age ranged from 18 to 63 years (average=40). There were 4 men and 2 women. The lower extremity was most frequentlyinvolvedin67%ofcases(n=3ankle,n=1knee)followedbythehandin33%ofcases.Alllesionswerecircumferential, intimatelyassociatedandsurroundingtheaffectedtendon.Lesionsizerangedfrom5–12cminCC(averagelength=7.7cm)x1.2– 4.5cminTRV(averagelength=3.4cm)x1.0–3.9cminAP(averagelength=2.7cm).T1weightedMRimagesshowedintermediate signalintensity(similartomuscle)inallcaseswithmildheterogeneity.T2weightedMRimagesrevealedintermediate(67%;n=4)to low (33%; n=2) signal intensity with moderate heterogeneity. Marked diffuse enhancement was seen in all cases evaluated with contrast(n=4). Conclusion: Imaging features of diffuse type giant cell tumor of tendon sheath are those of a long, > 5cm, circumferential mass intimatelyassociatedwithatendon.SignalcharacteristicsonMRaresimilartopreviousreportsofGCTTSandjointPVNS.Thelength andcircumferentialappearancemayaidindistinctionfromalargeormultifocalgiantcelltumoroftendonsheath.Itisimportantto understandthatthispatternofdiffuseinvolvementisnotonlyseeninPVNSofthejointbutalsorarelythetendonsheathtohelp guidethesurgicalexcision. 53 Podium #24 IMAGINGFEATURESOFSYNOVIALCHONDROMATOSISVERSUSCPPDDISEASEOFTHETEMPOROMANDIBULARJOINTWITH PATHOLOGICCORRELATION MarkMurphey;MatthewMinn;MaryKlassenFischer;MarkKransdorf AmericanInstituteforRadiologicPathology (Presentedby:MarkMurphey) Purpose:ToevaluatetheimagingappearanceofsynovialchondromatosisversusCPPDdiseaseofthetemporomandibularjoint(TMJ) withpathologiccorrelation. Materials and Methods: We retrospectively reviewed a total of 9 patients with pathologically confirmed intraarticular synovial chondromatosis(n=5)orCPPDdisease(n=4)oftheTMJ.Radiologicstudieswerereviewedbytwomusculoskeletalradiologistswith agreementbyconsensus.ImagingstudiesincludedCT(n=8)andMRI(n=5).Evaluationincludedpatientdemographics,lesionlocation, extentandcharacterofcalcificationsonCT,presenceandsiteoferosions,andintrinsicfeaturesonCTandMRI. Results:Patientagerangedfrom44to75years(average=59)with67%femalesand33%males.Alllesionswereintraarticularand centeredwithintheTMJ.Allcaseswerefoundtobeunilateral,involvingtherightsidein56%ofcasesortheleftsidein44%ofpatients. OnCT,synovialchondromatosisdemonstratedmultifocalareasofcalcificationwithinthejointrecessesoftheTMJwitherosionsof themandible(40%).CPPDdiseaseonCTrevealeddiffuseamorphouscalcificationcenteredatthearticulardiskofthemandiblewith erosions superiorly of the temporal bone (80%); one patient with concurrent radiographs also revealed chondrocalcinosis in the appendicularskeleton.OnMR,allcasesofsynovialchondromatosisandCPPDdiseasewereisointensetomuscleonT1withmild heterogeneity.Synovialchondromatosisdemonstrateslobular,intermediatesignalonT2weightedimageswithmildheterogeneity (100%;n=5).ThesinglecaseofCPPDdiseaseevaluatedwithMRrevealedisointensesignaltomuscleonT2withmildheterogeneity. Synovialchondromatosisrevealedmildperipheral,septalenhancement(100%;n=2),whereasCPPDdiseasehadmoderateperipheral, nodularenhancement(100%;n=1)onpostcontrastMRimaging. Conclusion:ImagingfeaturesofsynovialchondromatosisintheTMJaresimilartothatseenatotherintraarticularlocations.OnCT, synovial chondromatosis reveals multifocal areas of calcification with associated mandibular erosions. In contrast, CPPD disease reveals amorphous, tumoral calcification of the joint centered at the articular disk with temporal bone erosions. Synovial chondromatosis demonstrates mild peripheral, septal enhancement, whereas CPPD disease reveals moderate, peripheral nodular enhancement.TheseimagingfeaturesallowdistinctionbetweenthesetwodiseaseswithinvolvementoftheTMJ. 54 Tuesday Tuesday, March 10, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 7:00a.m.–7:55a.m. ContinentalBreakfast 7:00a.m.–12:30p.m. ExhibitHallOpen 7:00a.m.–12:35p.m. Registration/InformationDeskOpen 7:00a.m.–12:30p.m. ePosterSession* *Asthissessionisnotmoderated,ePostersarenotCMEaccredited 8:00a.m.–10:00a.m. UPPEREXTREMITYSESSIONI Moderators:RobertBoutin,MD;GinaDiPrimio,MD 8:00a.m. #25 DISPLACEMENTPATTERNSOFFULLTHICKNESSTEARSOFROTATORCUFFTENDONS LawrenceWhite;AlpeshMistry;DhirenShah;ChristianVeillette;JohnTheodoropoulos;AliNaraghi (Presentedby:LawrenceWhite,MD) 8:20a.m. #26 UltrasoundGuidedBicepsPeritendinousInjectionsintheAbsenceofaDistendedTendon Sheath:ANovelRotatorIntervalApproach TaylorStone;RonaldAdler (Presentedby:TaylorStone,MD) 8:40a.m. #27 Localizingthecenterofsmallrotatorcufftears:UseofMRlandmarksandthedistancefrom thebicepstendon MichaelJTuite;BrianChan;GeoffBaer;TamaraScerpella;JohnOrwin (Presentedby:MikeTuite,MD) 9:00a.m. #28 MRIEvaluationofBipolarBoneLoss:CanitBeUsedtoPredictFailureofArthroscopicShoulder Stabilization? SoteriosGyftopoulos;JaredBookman;AvnerYemin;JamesBabb;AndrewRokito (Presentedby:SoteriosGyftopoulos,MD) 9:15a.m. #29 Rotatorcufftearshapecharacterization:Acomparisonof2Dimagingand3DMR reconstructions SoteriosGyftopoulos;LuisBeltran;KevinGibbs;PhilipBerman;JamesBabb;LaithJazrawi;Robert Meislin (Presentedby:SoteriosGyftopoulos,MD) 9:30a.m. #30 Differentiatingosacromialefromnormaldevelopingacromialossificationcenterusing magneticresonanceimaging ZehavaSadkaRosenberg;MatthewWinfeld;AnnieWang;JennyBencardino (Presentedby:ZahavaRosenberg,MD) 9:45a.m. #31 ShoulderJointFluidDistributioninAdhesiveCapsulitis HilaryUmans;RamyaSrinivasan;JonathanTicker (Presentedby:HilaryUmans,MD) 10:00a.m.–10:05a.m. 10:05a.m.–10:30a.m. CASEOFTHEDAY: (Presentedby:KurtScherer,MD;ChristopherWasyliw,MD) Break–VisitExhibitHall 55 Tuesday, March 10, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 10:30a.m.–12:30p.m. HIPSESSION Moderators:DonnaBlankenbaker,MD;JoshuaPolster,MD 10:30a.m. #32 "Sonoarthrography"ofthehiplabrum:Ultrasoundevaluationoftheanterosuperioracetabular labrumfollowingjointdistensionwithMRarthrographiccorrelation TaylorStone;NiamhLong;CatherinePetchprapa;RonaldAdler (Presentedby:TaylorStone,MD) 10:50a.m. #33 HipMRArthrography:AreWeUnderdiagnosingSynovitisandLaxityPreoperatively? GeoffreyRiley;RussellStewart;JonathanPacker;MarcSafran;RobertBoutin (PresentedBy:GeoffreyRiley,MD) 11:10a.m. #34 VariabilityinHipImagingProtocols:AComparisonof107DifferentMRFacilities MattProctor;ScottWuertzer;ElizabethA.Howse;AllstonJ.Stubbs;LeonLenchik (Presentedby:MattProctor,MD) 11:30a.m. #35 TheAdductorMagnus"MiniHamstring":MRIAppearanceandPotentialPitfalls StephenBroski;NaveenMurthy;MarkCollins (Presentedby:StephenBroski,MD) 11:45a.m. #36 QuantitativeandQualitativeComparisonof3.0Tversus1.5TWARPImagingofHipProstheses LaurenM.Ladd;NathanA.Maertz;ChenLin;TrentonD.Roth;MathiasNittka;KeChengLiu;Bruce Spottiswoode;KennethA.Buckwalter (Presentedby:LaurenLadd,MD) 12:00p.m. #37 AnatomicVariantsoftheProximalLateralFemoralCortexThatMimicPrefractureFindingsof AtypicalFemoralFracturesonConventionalRadiographs TroyH.Maetani;StacyE.Smith;BarbaraN.Weissman (Presentedby:TroyMaetani,MD) 12:15p.m. #38 MRARTHROGRAPHYOFTHEHIP:COMPARISONOFIDEALSPGRVOLUMESEQUENCETO STANDARDMRSEQUENCESINTHEDETECTIONANDCHARACTERIZATIONOFACETABULAR LABRALTEARS JarrodDale;DonnaBlankenbaker;RichardKijowski;KirklandDavis;JamesKeene (Presentedby:JarrodDale,MD) 12:30p.m.–12:35p.m. CASEOFTHEDAY: (Presentedby:EiraRoth,MD;MichaelRichardson,MD) 56 Related ePosters FullePosterAbstractsareonPage165 UpperExtremityI ePoster#29 REVERSETOTALSHOULDERARTHROPLASTY:RADIOLOGICIMAGINGANDEVALUATION SailajaYadavalli;ErgentZhiva;SunitVekaria BeaumontHealthSystem ePoster#30 IMAGINGSPECTRUMOFPECTORALISTEARS:PREOPERATIVEANDPOSTOPERATIVEMRI FINDINGS ShefaliKothary;GabrielleKonin;DarrylSneag;FrankCordasco HospitalforSpecialSurgery ePoster#31 DIAGNOSTICACCURACYOFSHOULDERMRIINCHARACTERIZINGBICEPSTENDONPATHOLOGY UTILIZING STANDARD IMAGING PLANES VERSUS A DOUBLE OBLIQUE T2 WEIGHTED FAT SUPPRESSEDSEQUENCE ScottSheehan;HumbertoRosas;JasonStephenson UniversityofWisconsin ePoster#32 INFERIORSUBSCAPULARISMUSCLESTRAIN–ANUNUSUALFINDINGINOVERHEADTHROWING ATHLETESWITHPOSTERIORSHOULDERPAIN EricMTarkowski,KevinJBlount,StephenMGryzlo,ImranMOmar NorthwesternUniversityFeinbergSchoolofMedicine Hip ePoster#33 MRIMAGINGOFATHLETICPUBALGIA:NORMALANATOMY,COMMONFINDINGSAND PITFALLS AbhijitDatir;BinduAvutu;TarekNHanna;DouglasDRobertson EmoryUniversity ePoster#34 COMPLICATIONSOFHIPARTHROSCOPY JuliaCrim UniversityofMissouri ePoster#35 MRIOFPROXIMALFEMURMICROSTRUCTUREASNOVELBIOMARKERSOFSKELETALFRAGILITY ANDFRACTURERISK KevinChu;RonaldAdler;GregoryChang NewYorkUniversityLagoneMedicalCenter ePoster#36 TRAUMATICSACRALFRACTURES:THREEIMPORTANTFRACTURECATEGORIES PushpenderGupta;ScottWuertzer;LeonLenchik WakeForrestSchoolofMedicine ePoster#37 3DMRVS.3DCTOSSEOUSRECONSTRUCTIONSOFTHEHIPUSINGAGRADIENTECHOBASED2 POINTDIXONRECONSTRUCTION:ACOMPARISONSTUDY Avner Yemin; Luis S. Beltran; Jonathan Vigdorchik; Michael Bloom; James Babb; Soterios Gyftopoulos NewYorkUniversityLagoneMedicalCenter 57 Podium #25 DISPLACEMENTPATTERNSOFFULLTHICKNESSTEARSOFROTATORCUFFTENDONS LawrenceWhite;AlpeshMistry;DhirenShah;ChristianVeillette;JohnTheodoropoulos;AliNaraghi UniversityofToronto (Presentedby:LawrenceWhite,MD) Purpose:Toinvestigatetheincidenceofdisplacedrotatorcuff(RC)tendonsinpatientswithfullthickness(FT)rotatorcufftearson MRI. Materials & Methods: Following IRB approval, and waived consent, 1,223 consecutive cases referred for MRI assessment of the shoulderatonehospitalsitebetweenJanuaryandDecember2011,wereretrospectivereviewed.AllMRimagingwasperformedon 1.5Tor3T(SiemensAG)systems,utilizingmultichannelshouldercoils.Inallcases,astandardizedMRIprotocolwasperformed,which includedcoronalobliqueandaxialFSEintermediateweighted,aswellascoronalandsagittalobliqueFSET2weightedfatsuppressed acquisitions.AllcaseswithFTtearsoftheRC>1cminanteroposteriordimension,wereretrospectivelyreviewedinconsensusby2 Musculoskeletalradiologists.FullthicknessRCtearswereassessedfor;thelocationofRCtearingobserved,andwhethertearswere complete(involvingentireAPdimensionofRCtendons),orincompleteinextent.Allcaseswerefurtherevaluatedforthepresenceor absenceofRCtendontear“displacement”;definedasanteriorposterioranatomicdisplacementoftornRCtendons.Inallcaseswith displacedRCtendontears,theanteriorposteriorlocationoftendonmarginswasrecordedrelativetoanatomicallyintactportionsof theRC,thecoracoidprocess,andthescapularspine. Results:386shoulderMRIs(180females,206males)hadFTrotatorcufftears>1cminanteroposteriordimension(meanage61.3, range 3289 years). 231/386 had complete tearing of at least one rotator cuff tendon; 153/231 supraspinatous (SS), 2/231 infraspinatous(IS),8/231subscapularis(Sub),51/231SS+IS,8/231SS+Sub,and9/231SS+IS+Sub.In69casesofFTRCtears (69/231,29.9%),displacementoftornRCtendon(s)wasobserved.Alldisplacedtendontears(69/69)involvedacompletetearofthe displacedtendonandFTtearingofanadjacentsegmentoftheRC,withfivepatternsofdisplacementseen.Type1(18/69,26.1%); completetearSSmaintainingcontactwithaFTtearIS,displacingandretractingSSposteriorlyintothespinoglenoidnotch,forminga sling around the scapular spine. Type 2 (19/69, 27.5%); complete tear SS maintaining contact with a FT tear SubS, displacing SS anterioinferiorly,formingaslinganteriorlyaroundthecoracoid.Type3(22/69,31.9%);completetearofSS,withposteriorSStendon fibers displaced posteriorly into the spinoglenoid notch, and anterior SS tendon fibers displaced anteriorly around the coracoid (combinedType1and2).Type4(5/69,7.2%);completeSubStearwithSubStendondisplacedsuperiorlyandposteriorlyaroundbase ofthecoracoidwithoutdisplacementofSS.Type5(5/69,7.2%);completetearISdisplacedanterosuperiorlyintothesupraspinatus compartmentoftheRC. Conclusion:Displacedtearsofrotatorcufftendonscanoccur,anddisplayapredictablepatternbasedonextentofFTcompleteRC tendontearinginvolved.IdentificationofdisplacedFTrotatorcufftendontearsshouldbesoughtonpreoperativeMRimagingtoaid inpotentialpreoperativesurgicalplanning. 58 Podium #26 ULTRASOUNDGUIDEDBICEPSPERITENDINOUSINJECTIONSINTHEABSENCEOFADISTENDEDTENDONSHEATH:ANOVEL ROTATORINTERVALAPPROACH. TaylorStone;RonaldAdler NYULangoneMedicalCenter (Presentedby:TaylorStone) Purpose:Todeterminethesuccessrateofperformingtherapeuticperitendonousinjectionsofthelongheadbicepsinpatientswithout afluiddistendedtendonsheath,throughanovelrotatorintervalapproach. MaterialsandMethods:26patientswhowerereferredforlongheadbicepstendonsheaththerapeuticinjectionwereprospectively selectedbasedontheabsenceofafluiddistendedtendonsheathonultrasoundimagingattimeoftheprocedure.Ultrasoundguided needleplacementwasperformedattheleveloftherotatorintervalinallpatients,immediatelyproximaltothegenuofthetendon. Allinjectionswereperformedusingalinear14MHztransduceranda1.5inch,25gaugeneedlepositionedadjacenttothetendon. Needlepositionwasdeemedappropriatewithlackofresistancefollowinginjectionof1%lidocaineduringatestinjectionperformed duringrealtimevisualization.Oncelocationoftheneedlewasdeemedsatisfactory,thelidocainewasexchangedfor3ccofstandard therapeuticmixtureconsistingoftriamcinolone(40mg/cc)and0.5%ropivicaine.Proceduraltechnicalsuccesswasdeterminedby documentingfluiddistentionofthebicepstendonsheathwithultrasoundaftertheprocedure.Amajorityofpatientswereasked abouttheirpainattheconclusionoftheprocedure,andratedtheirimprovementasnone,partial,orcomplete.Whenavailable,the patient’schartwasfollowedtoevaluateforcomplicationsandclinicalfollowup. Results:Thepatientpopulationconsistedof11malesand15females,meanage45.5years(standarddeviationof10.7years).17 injectionswereperformedintherightarmand9wereperformedintheleftarm.Ofthe26patientswhowereinjected,all26(100%) had postinjection fluid distention of the proximal biceps tendon sheath, implying a 100% technical success rate. 15/26 (57.7%) patientshadapostprocedurepainleveldocumented.8/15(53%)reportedcompletepainrelief,6/15(40%)reportedpartialpain relief,and1/15(7%)reportednopainrelief.Nocomplicationswerereportedordocumentedinpatients’chartsaftertheprocedure. 3/26(12%)ofthepatientswentontoarthroscopyforfailureoftheinjectionstocontrolpainthelongterm.Arthoscopicfindingsin thethreepatientswithpainrefractorytoinjectionincludedlooselabralsutureswrappedaroundthebicepstendon,atype1SLAP tear,andmildintraarticularbicepstendinosisinthethreepatients,respectively. Conclusion:Inpatientswithoutafluiddistendedtendonsheath,asafeandaccurateperitendinouslongheadbicepsinjectionmaybe performedviatherotatorinterval. 59 Podium #27 LOCALIZINGTHECENTEROFSMALLROTATORCUFFTEARS:USEOFMRLANDMARKSANDTHEDISTANCEFROMTHEBICEPS TENDON MichaelJTuite;BrianChan;GeoffBaer;TamaraScerpella;JohnOrwin UniversityofWisconsinSMPH (Presentedby:MichaelJTuite,MD) Purpose:Althoughmultiplepapersidentifytheanteriorsupraspinatustendon(SST)asthemostcommonlocationforsmallrotator cufftears,arecentultrasoundarticlesuggestedthatmosttearsarecenteredattheSST/infraspinatus(IST)junctionwhenmeasuring thedistanceofthetearfromthebicepstendon(BT)andcomparingittopublishedwidthsoftheSSTfootprint.Thepurposesofthis studywereto1)determinetheaveragedistancefromtheBTtothecenterofsmallcufftearsusingMR,and2)uselandmarksonMR todetermineinwhichtendonmosttearsoccur. Materials&Methods:WithIRBapproval,wereviewedtheoperativereportsof176consecutivepatientswhohadashoulderMR followedbyarthroscopy.PatientswereincludedinthestudyiftheyhadanintactBT,andapartialorfullthicknessSSTand/orIST tear that was <or= 2cm in diameter. 80 patients with 84 tears met the inclusion criteria. Two radiologists (one musculoskeletal fellowshiptrained,onea2ndyearresident)separatelyidentifiedthetearonMR,confirmingthelocationusingtheoperativereport andarthroscopyimages.WemeasuredtheshortestdistancefromtheBTtotheedgeofthetearusingobliquesagittalimages.We thendeterminedthesectionwiththemaximumAPwidthofthetear,dividedthetearwidthby2togettheradiusofthetear,and addedthattotheBTtotearedgedistancetocalculatethedistancefromtheBTtothecenterofthetear.Todeterminewhichtendon containedthecenterofthetearweidentifiedtheanteriormarginoftheISTonobliquesagittalimagesandtraceditlaterallytothe junctionofthesuperiorandmiddlefacetsofthegreatertuberosity,andthenmeasuredthedistancefromthispointtothecenterof thetearontheimagewiththemaximumtearwidth.Intraclasscorrelationcoefficient(ICC)wasusedtoassessinterobservervariability fortheBTtotearcenterdistance. Results:Forthemusculoskeletalradiologist,theaveragedistancefromtheBTtothecenteroftearswas16mm(range841mm,s.d. 6.1mm).ThecenterofthetearprojectedtowithintheSSTin70tears;totheanterioredgeoftheISTin3tears;andthemiddlefacet in11tears.Therewaspoorinterobserveragreement,withanICCof0.03. Conclusions:TheaveragedistancefromtheBTtothecenterofsmallcufftearsonMRissimilartothatreportedwithultrasound.The centerof83%ofsmallcufftearsprojecttobeingwithintheSST,with49%atleast7mmanteriortotheanteriormarginoftheIST. MeasuringthedistanceoftearsfromthebicepstendonandusingpreviousmeasurementsofthewidthoftheSSTfootprintcorrelates poorlywithlocalizingtearstotheSSTorIST.Thedistancemeasurementhaspoorreproducibilitybetweenamusculoskeletalradiologist andaradiologyresident. 60 Podium #28 MRIEVALUATIONOFBIPOLARBONELOSS:CANITBEUSEDTOPREDICTFAILUREOFARTHROSCOPICSHOULDERSTABILIZATION? SoteriosGyftopoulos;JaredBookman;AvnerYemin;JamesBabb;AndrewRokito NYULangoneMedicalCenter (Presentedby:SoteriosGyftopoulos) Purpose:ToseeiffailureofarthroscopicshoulderstabilizationcanbepredictedbytheevaluationofbipolarbonelossonMRI Methods: A retrospective review of 39 consecutive patients (40 shoulders) who underwent arthroscopic capsulolabral repair for recurrent,traumatic,anteriorshoulderinstabilitywasperformed.Therewereatotalof40MRIsfrom39patients(31males,8females, mean age 31.7 yrs). Mean followup was 19 months. Preoperative plain radiographs, MRI scans, operative reports, arthroscopic photos,andpostoperativerecordswerereviewedforeachpatient.Surgicalfailurewasdefinedasrecurrentshoulderdislocation and/orpersistentapprehensionduringnormalrangeofmotion.EachpreoperativeMRIscanwasevaluatedforbipolarbonelossby onemusculoskeletalradiologistusingtheontrack/offtrack(OOT)methodinwhichtheglenoidtrack(GT)andHillSachsinterval(HSI) aremeasured.Accordingtothistechnique,theGTiscalculatedas0.83Ddinwhich“D”representsthediameteroftheintactglenoid and“d”correspondstotheamountofglenoidboneloss.TheHSIrepresentsthewidthoftheHillSachslesionplusthewidthofthe intactbonebridgebetweentherotatorcuffattachmentandthelateralaspectoftheHillSachslesion.Allmeasurementswerein millimeters.Lesionswereconsidered“offtrack”iftheHSIexceededtheGTand“ontrack”iftheHSIwaslessthantheGT.These findingswerethencomparedtothecorrespondingpostoperativeoutcomes.StatisticalanalysiswascarriedoutusingtheFisherexact test. Results: Of the 40 shoulders evaluated, 6 were considered surgical failures (3 with recurrent dislocation and 3 with persistent apprehension).TheOOTmethodcorrectlypredicted1ofthesefailuresandfalselypredicted6failuresinshouldersthatwereclinically stable. There was no significant difference when comparing stable tounstable shoulders with regards to age, size of GT and HSI. Overall, the OOT method sensitivity was 16.7% (1/6), specificity 82.4% (28/34), positive predictive value 14.3% (1/7), negative predictivevalue84.9%(28/33)andoverallaccuracy72.5%(29/40). Conclusion:MRIevaluationofbipolar(humeralandglenoid)bonelossusingtheontrack/offtrackmethodisamoderatelyaccurate andspecific,butinsensitivetechniquetopredictsurgicalfailureafterarthroscopiccapsulolabralrepairforshoulderinstability. 61 Podium #29 ROTATORCUFFTEARSHAPECHARACTERIZATION:ACOMPARISONOF2DIMAGINGAND3DMRRECONSTRUCTIONS SoteriosGyftopoulos;LuisBeltran;KevinGibbs;PhilipBerman;JamesBabb;LaithJazrawi;RobertMeislin NYULangoneMedicalCenter (Presentedby:SoteriosGyftopoulos) Purpose:Toseeif3DimagingcouldimproveourunderstandingofrotatorcufftendontearshapesonMRI. Methods:Weperformedaretrospectivereviewof1.5T/3TMRexaminations,conductedoveran18monthperiod,ofpatientswith arthroscopically proven full thickness rotator cuff tears. Two orthopaedic surgeons reviewed the operative reports/arthroscopic photosforeachpatient,andcharacterized,inconsensus,theshapeofthetearbasedonacomparisonofthetear’swidth(size)and length (retraction), and involvement of the rotator interval without measurements into the following categories: crescent, longitudinal, U or Lshaped longitudinal, and massivetype. Two musculoskeletal radiologists reviewed the preoperative MR examinationforeachpatientindependently/blindtothearthroscopicfindings.Initially,thereaderscharacterizedtheshapeofthe tendontearsbyreviewingthestandard2DMRsequencesandusingthesamecriteriaasthesurgeonsusedduringtheirreviewofthe scopeimages.Next,thereadersmeasuredanddocumentedthewidthandlengthofeachtendontearusingthe2Dimages.Theshape ofthetearwasthenclassifiedbasedonapreviouslypublishedMRbasedsystemaseithercrescent,longitudinal,UorLshaped,or massive.Fourweeksaftertheinitialimagingevaluation,3DMRreconstructionsofeachtearwerereviewedandtheshapedocumented byeachradiologistindependently/blindtothearthroscopicresultsusingthesamesystemusedbyourorthopaediccolleagues.These resultswerethencomparedtothe2Dimagingevaluationsandarthroscopicfindings.Statisticalanalysisincluded95%confidence intervals,McNemartest,andintraclasscorrelationcoefficients. Results: A total of 34 patients were included in the study; 21 had crescent shaped tears and 13 had longitudinal tears during arthroscopy.Ofthe13longitudinaltears,8weresubtypedasUshaped,while5weredescribedasLshaped.6ofthe13longitudinal tearswereadditionallyclassifiedasmassivetype.Therewasnosignificantdifferencewhencomparingtheaccuracyofthetearshape characterizationsmadeon2DMRimagingwithoutmeasurements(pre)andwithmeasurements(post).Theaccuracyfordifferentiating betweencrescentshaped,longitudinal,andmassivetearswasthesameforreader1,70.6%(24/34;p=1)andmoreaccurateusingthe post2Ddataforreader2(67.6%(post)vs.61.8%(pre),p=0.5).Theaccuracyfortearshapecharacterizationbetweencrescentand longitudinalusingthe3Dreconstructionsforreader#1was97.1%(33/34)and88.2%(30/34)forreader#2.Whenthischaracterization includedsubclassifyingthelongitudinaltearsintoUorLshaped,theaccuracyforreader#1was97.1%and82.4%forreader#2.When furthercharacterizingthelongitudinaltearsasmassiveornot,bothreadershadanaccuracyof76.9%(10/13).Theoverallaccuracyof the3Dreconstructionswas82.4%(56/68),significantlydifferent(p=0.021)fromthepost2Daccuracy(64.7%)andpre2Daccuracy (60.3%,p=0.001).Theintraclasscorrelationcoefficientforthe2Dmeasurementsofwidthandlengthwere0.81,moderateagreement, forwidthand0.95,strongagreement,forlength. Conclusion:Ourstudyhasdemonstratedthat3DMRreconstructionsoftherotatorcuffimprovetheaccuracyofcharacterizingrotator cufftearshapescomparedtothecurrent2DMRimagingbasedtechniques. 62 Podium #30 DIFFERENTIATINGOSACROMIALEFROMNORMALDEVELOPINGACROMIALOSSIFICATIONCENTERUSINGMAGNETICRESONANCE IMAGING ZehavaSadkaRosenberg;MatthewWinfeld;AnnieWang;JennyBencardino NYUHospitalforJointDiseases (Presentedby:ZehavaSadkaRosenberg) PURPOSE:Accordingtocurrentliterature,fusionoftheacromionmaynotbecompleteuntiltheagesof1825,makingitquestionable todiagnoseosacromialeinadolescents.Wehypothesizethatosacromialemayexistinpediatricpatientsandcanbedifferentiated fromadevelopingacromialossificationcenter(s)basedonmagneticresonanceimaging(MRI)findings. METHODS:128consecutiveMRIsoftheshoulder,performedatourinstitutionfrom11/201111/2013,wererandomlyandblindly reviewedretrospectivelybytwomusculoskeletalradiologists.Thecasesincluded56MRIsofosacromiale(mesoacromion)inadults overage25(2574yearsold,mean50years)and72MRIsinchildrenaged1217(mean14.5years).Thefollowingvariablesatthe interface between the distal acromion and os acromiale or developing ossification center(s) were assessed: presence of an os acromiale vs. developing acromion, interface orientation, interface margins, and presence of edema within and adjacent to the interface.Basedontheliterature,osacromialewasdefinedashavingatransverse/oblique,irregularinterfacewiththerestofthe acromionwhileanormaldevelopingacromionwasdefinedashavinganarced,lobulatedinterfacewithitsossificationcenter(s). RESULTS:Thefinalcohortcomprised100cases(51adultswithosacromialeand49adolescents).Caseswereexcludedduetopoor imagequalityorconfoundingfindings(n=7)orbecauseofcompleteacromialfusion(n=21adolescents).Alladultcases(100%)were accurately diagnosed as having os acromiale by both readers, with predominantly transverse interface orientation and irregular margins(94%,R=0.86,p<0.00001).Fortyfive(92%)oftheadolescentcaseswereaccuratelydiagnosedbybothreadersashavinga normallydevelopingacromionwitharcedinterfaceandlobulatedmargins(92%,R=0.92,p<0.000001).Four(8%)adolescentcases (ages1517)werediagnosedashavingosacromiale,withtransverseorientationandirregularmargins.Thirtyfive(69%)and46(90%) adultcaseshadmarrowandinterfaceedema,respectively.Bycomparison,6(12%)and8(16%)adolescentshadmarrowandinterface edemarespectively,includingthefourcasesconcludedtobeosacromiale. DISCUSSON: Adolescents may have imaging findings consistent with os acromiale, depicting a transverse, irregular interface with edemaatandsurroundingtheinterface.Thus,theMRIdiagnosisofosacromialeshouldbebasedonspecificimagingfeaturesandnot limitedbypatientage. 63 Podium #31 SHOULDERJOINTFLUIDDISTRIBUTIONINADHESIVECAPSULITIS HilaryUmans;RamyaSrinivasan;JonathanTicker LenoxHillRadiology&ImagingAssociates (Presentedby:HilaryUmans) Object:Todeterminewhetheradhesivecapsulitisaffectsfluiddistributionintheglenohumeraljointandlongheadbicepstendon sheath. Materials & Methods:Sixty shoulder MRI in patients (34 females, 26 males, mean age 52 years) with adhesive capsulitis diagnosedbyclinicalevaluationandimagingcriteria(1.5or3.0T,8/22/113/21/14)werereviewedretrospectivelyinconsensusbya blindedmusculoskeletalradiologistandashouldersurgeon.Sixtycontrolcases(24females,36males,meanage47years)weredivided equallyamongrotatorcufftendinosis,rotatorcufftearandarthroscopicallyprovenSLAPlesions.Therelativedistributionoffluid signalbetweenthesuperiorsubscapularisrecess(SSR),bicepstendonsheath(BTS)andcentralglenohumeral(GHJ)jointwasassessed qualitatively.Casesofnoorminimalfluidwereflagged.30MRI(15cases,15controls)wererandomlyduplicatedandembeddedin thestudygroupinordertoassessintraobserveragreement.Thedegreeanddistributionofcapsularthickeningwasindependently determinedbyablinded,seniorradiologyresident.Statisticalanalysisinvolvedcreationofcontingencytablesusingqualitativefluid distribution results in adhesive capsulitis versus control cases. Fisher’s test was used to compute statistical significance, and sensitivities, specificities, positive and negative predictive values were calculated. Intraobserver agreement was evaluated by calculating kappa values. Exclusion criteria included biceps tendinosis and massive rotator cuff tear with displacement and/or disruptionofthelongheadbicepstendon. Results:Inpatientswithadhesivecapsulitis,57/60(95%)hadmorefluidintheSSRand/orBTSthaninthecentralGHJ,comparedto 18/60 (30%) of controls (sensitivity 0.95, specificity 0.70, p<0.0001). Intraobserver agreement was excellent (kappa 0.93). 52% of controlsand17%ofcaseshadnoorminimalfluid.Inbothcasesandcontrols,brightorintermediatecapsularsignalwasassociated withgreaterfluidintheSSRand/orBTSthaninthecentralGHJ(p=0.002).Therewasnocorrelationbetweenthedegreeordistribution ofcapsularthickeningandfluiddistribution. Conclusion:DisproportionatedistentionoftheSSRandBTSonMRIarehighlysensitiveandmoderatelyspecificfindingsthatcanbe usefulinsupportingthediagnosisofadhesivecapsulitis.Althoughthesefindingsarelogicalandinkeepingwiththetendencyfor adhesivecapsulitistodecreasecentralGHJcapacitytherebyshiftingfluidintotheSSRand/ortheBTS,theyhavenotbeenpreviously validated. 64 Podium #32 “SONOARTHROGRAPHY”OFTHEHIPLABRUM:ULTRASOUNDEVALUATIONOFTHEANTEROSUPERIORACETABULARLABRUM FOLLOWINGJOINTDISTENSIONWITHMRARTHROGRAPHICCORRELATION. TaylorStone;NiamhLong;CatherinePetchprapa;RonaldAdler NYULangoneMedicalCenter (Presentedby:TaylorStone) Purpose:Apreviousstudyhassuggestedthatsonographicassessmentoftheacetabularlabrumfollowingintraarticularinjection demonstrated concordance between sonographic and noncontrast MRI findings of labral pathology. However, the time interval betweensonographicimagingandMRIvariedsignificantly,andnoncontrastMRIislessaccurateindiagnosinglabraltearsthanMR arthrography.WewishtoverifywhethersuchconcordanceexistswhensystematicallycomparedtoMRAperformedonthesameday. MaterialandMethods:Imagingfrom26patientswhowerereferredforhipdirectMRarthrographywithultrasoundguidancewere retrospectivelyreviewedforthisstudy.USguidedhipinjectionwasperformedwitha6MHzcurvedtransduceranda3.5inch,22 gaugeneedleaccordingtothedepartment’sstandardprotocol.Adilutegadoliniummixtureof10ccofnormalsalineand0.1ccof gadoliniumcontrastand2ccof1%lidocainewasadministeredinallcases.Routinepostinjectionultrasoundimagingexaminationof theanterosuperiorlabrumwasperformedfromtheiliopsoastendontotherectusfemoristendonusingalinear9MHztransducerby anexperiencedMSKradiologist.Subsequently,patientsproceededdirectlytoMRimaging.SamedayultrasoundandMRAimages wereretrospectivelyandblindlyreviewedinrandomorderbytwoexperiencedMSKradiologistsafterthestudieswereanonymized. Thelabrumforeachstudywasdividedintothreeanatomicalzones:adjacenttoiliopsoastendon,adjacenttorectusfemoristendon, andbetweenthetwotendons.Foreachmodalityandanatomiczone,thelabrumwasgiventhreebinarynumericalscoresdenoting thepresenceorabsenceofthefollowing:intrasubstancelabralcleft,chondrolabraljunctioncleft,andabnormallabrummorphology. The values for each labrum anatomical zone and pathology were then compared. MRA was considered the gold standard for diagnosinglabraltears. Results: Thepatientpopulationconsisted of 11 males and 15females,mean age33.5years (standard deviationof 9.1years).11 injectionswereperformedinthelefthipand15wereperformedintherighthip.Themeanbodymassindex(BMI)was23.7(standard deviationof4.1).4patientswereeventuallytakentoarthroscopyandtheMRAfindingswereconfirmed.Giventhatthepresenceor absenceoflabralcleft,chondrolabraljunctioncleft,andabnormalmorphologywasincludedforeachlabrumanatomicalzone,234 datapointswereobtainedforUSandMRevaluation.USandMRshowedmatchinganalysisin124/234(53%)ofthedatapoints.3/26 (11.5%)patientshadnormallabrumMRAexaminations.Onazonalbasis,USwasmostaccurateindetectingabnormalmorphology (LR+1.59,LR0.388).USwasalsomoderatelyaccuratedetectinglabralcleftsonazonebasis(LR+1.35,LR0.58).UScalledsomeform ofpathologyneartherectusfemorisandbetweenthetendonsinallpatients,withPPVof0.577and0.692ineachzonerespectively. 65 Podium #33 HIPMRARTHROGRAPHY:AREWEUNDERDIAGNOSINGSYNOVITISANDLAXITYPREOPERATIVELY? GeoffreyRiley;RussellStewart;JonathanPacker;MarcSafran;RobertBoutin StanfordUniversity (Presentedby:GeoffreyRiley) INTRODUCTION: Edemalikesignal in adipose tissue is recognized widely asan importantdiagnosticfinding on MR examinations, includingintherotatorintervaloftheshoulder(associatedwithadhesivecapsulitis)andinthesuperolateralaspectoftheHoffa’sfat padintheknee(associatedwithpatellarmaltracking).However,wearenotawareofanysystematicMRevaluationofsignalintensity changesinthehippulvinarforapossibleassociationwithpain,synovitis,orfindingsoflaxity. OBJECTIVES:To(1)determinethefrequencyofedemalikesignalintensityinthepulvinar;(2)correlatealteredsignalinthepulvinar withthepresenceofsynovitis,usingarthroscopyasthereferencestandard;and(3)assessthefrequencyofjointcapsulefindingsthat havebeenassociatedwithlaxityandmightbeassociatedwithsynovitis. MATERIALSANDMETHODS:AfterobtainingIRBapproval,weidentified20consecutivepatientsatourinstitutionundergoinghipMR arthrographyandsubsequentarthroscopybyasinglesubspecialtyhiparthroscopist,withaminimum1yearpostoperativefollowup using standardized clinical scoring (WOMAC and iHOT33). (Exclusion criteria included the presence of hip hardware, fracture, or tumor.)TheoriginalMRreportwasreviewedspecificallyforthepreoperativediagnosisofsynovitisandlaxity.Twomusculoskeletal radiologistsblindedtosurgicalresultsthenrereviewedtheMRarthrogramsprospectivelyfor12features,byconsensus,including(i) thesignalintensityofthepulvinar[gradedas0,normalfattysignal;1,highT2signal(withnormalsignalonT1weightedimages);2, highT2andlowT1signal;3,lowT1andT2signal]and(ii)morphologicsignsthathavebeenassociatedwithhiplaxity[wideningofthe anteriorhipjointrecess(>5mm)andthinningoftheadjacentjointcapsule(<3mm)].Anorthopaedicsurgeon(blindedtoMRfindings) reviewedthearthroscopyreportsandintraoperativeimages,includingfor(a)thearthroscopicdiagnosisoffocalpulvinarsynovitis, generalarticularsynovitis,andlaxityand(b)arthroscopictreatmentwithsynovectomyandcapsularplication. RESULTS:Thepatients(15women,5men)rangedinagefrom11to54years(average,34),allofwhomhadhippain.TheoriginalMR reports did not specify the diagnosis of synovitis (0/20) or laxity (0/20). Rereview of the MR exams showed the pulvinar was remarkableforsignalintensitychangesin4of20patients(edemalikein4andfibroticappearinginnone);allfourofthesepatients hadpulvinarsynovitisatarthroscopy.ThedualMRcriteriaassociatedwithlaxitywereobservedin7of20patients;4ofthesepatients showedlaxityatarthroscopy.Atarthroscopy,17/20patientshaddocumentedfocalpulvinarsynovitis(5mild,6moderate,6marked), aswellasvaryingdegreesofsynovitiselsewherethatwastreatedwithsynovectomy(20/20).Arthroscopicdiagnosisoflaxitywas common(presentin12;absentin8),andwastreatedwithcapsularplication(12/20). CONCLUSIONS:HipsynovitisandlaxitycommonlyareunderdiagnosedonpreoperativeMRreports,comparedtoarthroscopy.New MRfindingsassociatedwithsynovitisandlaxitymayimprovethedetectionofsynovitisandlaxitythatarediagnosedandtreated duringhiparthroscopy. 66 Podium #34 VARIABILITYINHIPIMAGINGPROTOCOLS:ACOMPARISONOF107DIFFERENTMRFACILITIES MattProctor;ScottWuertzer;ElizabethA.Howse;AllstonJ.Stubbs;LeonLenchik WakeForestUniversitySchoolofMedicine (Presentedby:MattProctor) Purpose: The current ACRSPRSSR Practice Guideline for MRI of Hip and Pelvis includes recommendations on hip MR and MR arthrographyprotocols.OurpurposewastoevaluatethepreoperativehipMRexaminationsfromdifferentMRfacilitiesusedbya singlesurgeontodeterminehowmuchvariabilityexistsinhipMRprotocolsandiftheprotocolsfollowACRrecommendations. Methods:Wereviewedthemedicalrecordsofallfirsttimehiparthroscopycasesperformedbyonesurgeonfrom1/1/2012and 7/30/2014.AllpreoperativestudiesobtainedoutsideofourinstitutionwerecategorizedaseitheraconventionalMR(MRC)oranMR arthrogram(MRA).ForeachMRstudy,thefollowingfeaturesoftheprotocolwererecorded:Imagingplanes,pulsesequences,and fieldofview.AccordingtotheACRrecommendations,MRCstudieswerereviewedforthepresenceofanonfatsaturatedT1weighted (NFST1)sequenceandMRAstudiesforthepresenceofafluidsensitivesequenceandaNFST1sequence. Results:Therewere220MRstudiesobtainedfrom107differentMRfacilities,outsideofourinstitution.Thepatientagerangedfrom 113to64years(mean34).Ofthe220studies,214(97%)includedatleasttwostandardimagingplanes(axial,coronal,orsagittal)and 93(42%)includedanadditionalobliqueaxialplane.Alargefieldofviewofentirepelviswasincludedin161/220(73%)ofstudies.Of the220studies,58(26%)wereMRCsand162(74%)wereMRAs.ANFST1sequencewasnotincludedin1/58(2%)oftheMRCsand 38/162(23%)oftheMRAs.Afluidsequencewasnotincludedin6/162(4%)oftheMRAs.Ofthe107MRfacilities,aNFST1sequence wasnotincludedin26(24%)protocolsandafluidsequencewasnotincludedin6(6%)ofprotocols.Radialimagingwasusedat4/107 (4%)facilities. Conclusion:Basedonthepreoperativeimagingforasinglearthroscopist,thereisconsiderablevariabilityinhipMRimagingprotocols fromdifferentfacilities.DespiteACRrecommendations,manyMRarthrographyprotocolsdonotincludeaT1weightedsequence withoutfatsaturationorafluidsensitivesequence. 67 Podium #35 THEADDUCTORMAGNUS“MINIHAMSTRING”:MRIAPPEARANCEANDPOTENTIALPITFALLS StephenBroski;NaveenMurthy;MarkCollins MayoClinic (Presentedby:StephenBroski) Objective:Theadductormagnusischiocondylarportionoradductormagnus“minihamstring”(AMMH)canoccasionallybeasource ofconfusiononMRIinpatientswithhamstringinjury.Thisisparticularlytrueincasesofcompletehamstringavulsion,whereitmay mimic an intact but attenuated semimembranosus tendon (SMT). This study was undertaken to 1) elucidate the anatomic characteristicsoftheAMMHonMRIand2)definehowoftenthistendonisinvolvedincasesofhamstringavulsion. MaterialandMethods:WithIRBapproval,aretrospectivereviewofourinstitutionaldatabasewasperformedforpatientsundergoing “hamstring protocol” MRI between 3/2009 and 6/2014. Two experienced musculoskeletal radiologists analyzed the MRIs by consensus.AMMHanatomicanalysiswascarriedoutontheunaffectedsideincasesofhamstringinjury,orbothsidesinthosewithout significanthamstringpathology.AxialPDMRIimagesatthepointofbesttendondefinition1.01.5cmbelowtheischialtuberosity wereusedtomeasureacrosssectionalarea(CSA),maximaldiameter,andmedialdistancefromtheSMT.Tendonvisualization(poorly visualized,visualized,wellvisualized),tendonmorphology(round,ovoid,flat/lenticular),andlocationoftheischialtuberositytendon attachmentwerenoted.Thedefinedtendonlengthfromtheischialorigintoitsjunctionwiththeadductormagnusfasciaormuscle bellywasalsomeasured.Finally,AMMHinvolvementandappearanceincasesofhamstringavulsionwasnoted. Results:76AMMHswereanalyzedin66patients.Therewere35femalesand31maleswithameanageof49.3+/15.2years(range 1781).9(11%)AMMHswerepoorlyvisualized,39(51%)visualized,and28(37%)wellvisualized.Therewere5(7%)round,55(73%) ovoid, and 16 (21%) flat/lenticular tendon morphologies. 67 AMMHs demonstrated typical origins, arising from the inferomedial aspect of the ischial tuberosity. Of the 9 with atypical origins, 6 were more posterior than normal, 3 more medial, and 1 more posteromedial.TheaverageCSAwas22.4+/10.6mm2(range656),diameterwas7.2+/2.5mm(range2.915),andmedialdistance fromtheSMTwas7.5+/2.5mm(range314).16cases(21%)hadamedialdistancefromtheSMTof5mmorless.Theaverage definedtendonlengthwas6.8+/3.3cm(range1.2–14.1).TherewasnosignificantdifferenceinAMMHlength,CSA,diameter,or medialdistancefromtheSMTbetweenmalesandfemales,thoughCSAdifferencestrendedtowardsignificance(onewayANOVAp= 0.054).Bivariateanalysisfailedtodemonstratearelationshipbetweenageandcrosssectionalareaordiameter.17casesofcomplete hamstringavulsionwereencountered.TheAMMHwasintactin13casesandpartiallytornin4. Conclusion:TheAMMHisaconstantfindingwithvariableanatomiccharacteristics.ItisvisualizedorwellvisualizedbyMRIinthe majorityofcasesandusuallyasizabletendonlocatedincloseproximitytothesemimembranosustendon.Giventhatitisuncommonly injuredincasesofcompletehamstringavulsion,radiologistsshouldbeawareofitspresenceandappearancetoavoiddiagnostic confusion. 68 Podium #36 QUANTITATIVEANDQUALITATIVECOMPARISONOF3.0TVERSUS1.5TWARPIMAGINGOFHIPPROSTHESES LaurenM.Ladd;NathanA.Maertz;ChenLin;TrentonD.Roth;MathiasNittka;KeChengLiu;BruceSpottiswoode;KennethA. Buckwalter IndianaUniversity (Presentedby:LaurenM.Ladd) Purpose:Tocomparemagneticresonanceimagingofhipprosthesesinthesamepatientsat1.5Tand3.0Tusingsliceencodingmetal artifactcorrection(SEMAC)andviewangletilt(VAT)andtodetermineif3.0Timagingisviableforclinicaluseassessinghipprostheses andperiprostheticanatomy. Methods:Thestudywasapprovedbyourinstitutionalreviewboard.Thirteenhipsinninepatients(4male,3female;meanage56 years)withprosthetichipimplantswereimagedatboth1.5Tand3.0T.Thescannersat1.5Tand3.0Thavethesameboresize,gradient performance,andmetalartifactsuppressiontechniques,includingSEMAC,VAT,andhighbandwidthradiofrequencypulses.Standard imagingplanesandcontrastswereobtainedandscantimeswereoptimizedforclinicaluse(<10minutes/scan,<60minutes/total exam).Theimagingparameterswereoptimizedfor1.5Tand3.0T,respectively.Anindependent,blindedreviewwasperformedby threefellowshiptrainedmusculoskeletalradiologists.Artifactareawasmeasuredonrepresentativeimagesfromeachimagingplane andqualitativeanalysisofbone,jointfluid,andsofttissuevisibilitywasassessedusinga5pointLikertscale(1=nodistortingartifact; 5 = severe artifact, uninterpretable images). Quantitative data was analyzed using linear mixed models and qualitative data was analyzed using generalized estimating equations models. Intraclass correlation coefficients were calculated to assess reader agreement. Results:Metalartifactareawasconsistentlylesswith1.5Tthan3.0Tanddemonstratedstatisticalsignificanceinallplanes(mean artifactareaoncoronalT1,2693mm2vs.3935mm2,p<<0.001;coronalSTIR,2999mm2vs.4599mm2,p<<0.001;sagittalT1,3274 mm2vs.4632mm2,p<<0.001;sagittalSTIR,3625mm2vs.4415mm2,p=0.009;axialIR,3042mm2vs.4797mm2,p<<0.001). Visibilityofperiarticulartissueswassubjectivelybetterwith1.5Tversus3.0T,gradedona5pointLikertscale(bones,2.9vs.3.8,p<< 0.001;jointfluid,2.4vs.3.1,p=0.001;softtissues,2.2vs.2.9,p<<0.001).However,subjectivescoresof3.0Timagesaverageless than4(moderate to large amount of artifact,definitelyobscures some structures and likely affects interpretability). Figure1 is a representativeexampleofthe1.5T(A)and3.0T(B)imagingcomparisonofthesamehipprosthesis,ofwhichbothimagesdemonstrate jointfluid.Readeragreementwasgoodtoexcellentforquantitativeandexcellentforqualitativeassessments. Conclusion: Metal hip prosthesis artifact reduction is significantly better with 1.5T magnet strength. However, 3.0T images demonstrateacceptableassessmentofsurroundingjointstructuresinmanypatientsandisreasonableforclinicaluseifalternative imagingisnotpossible. 69 Podium #37 ANATOMICVARIANTSOFTHEPROXIMALLATERALFEMORALCORTEXTHATMIMICPREFRACTUREFINDINGSOFATYPICAL FEMORALFRACTURESONCONVENTIONALRADIOGRAPHS TroyH.Maetani;StacyE.Smith;BarbaraN.Weissman BrighamandWomen'sHospital,HarvardMedicalSchool (Presentedby:TroyH.Maetani,MD) Purpose:Atypicalfemoralfractures(AFF)inthelateralsubtrochantericfemurarewellknownadverseeventsofbisphosphonateand denosumabuse.SeveralstudieshavedescribedprefracturefindingsofAFFonimaging,whichincludeslocalizedperiostealthickening. Wehavefoundperiostealthickeninginthelateralproximalfemurinpatientsnaïvetobisphosphonateanddenosumabtherapy.The purposeofourstudywastoevaluatelateralfemoralcortexvariantsthatmaymimicprefracturefindingsofAFF. Methods:Weretrospectivelyreviewedfemurradiographsof1493patients(agerange18to91,804women)from2002to2014. Patients with a history of prior femoral surgery, primary or metastatic bone lesions, and miscellaneous bone disease (eg Paget’s disease, fibrous dysplasia) were excluded. A positive study was defined as localized lateral subtrochanteric femoral periosteal thickening.PositivestudieswereassignedtotheprefracturecohortiftherewereprodromalsymptomswithacontralateralAFFor classicbeakingperiostealthickeningofthelateralfemoralcortexinconjunctionwithbisphosphonateordenosumabuseorasnormal variants.Periostealthickeningwidthanddistancesfromthesuperiorfemoralheadandbelowthelevelofthelessertrochanterwere measured,andstatisticalanalysiswasperformedwithattest(p<0.01).Patientdemographicswereobtainedwiththetype,dose,and duration of therapy in cases of bisphosphonate or denosumab use. All available crosssectional imaging for positive studies were reviewedandanatomicalcausesoftheradiographicfindingsweredetermined. Results:Ofthe1493examsreviewed,1079metinclusioncriteria.Twentyfourpatients(2.2%)werefoundtohavelocalizedlateral femoralperiostealthickening(14unilateral,11bilateral).Sixpatientshadahistoryofbisphosphonateuse(mean5.67years)and2 withdenosumabuse(totalof2and7doses,respectively),butonly3hadprodromalsymptomswithhistoryofcontralateralAFFor classicbeakingperiostealthickening(2onbisphosphonateand1ondenosumabtherapy)andassignedtotheprefracturecohort.The remaining21patientswereclassifiedasnormalvariants.Theprefracturecohorthadameanwidthof4.33±1.2mm,meanfemoral headdistanceof161.7±3.5mmandsubtrochantericdistanceof58.3±11.6mm.Inthenormalvariantgroup,themeanwidthwas 2.6±0.9mm,thefemoralheadandsubtrochantericdistanceswere103.1±15.7mmand3.1±12.5mm,respectively(p<0.01). Availablecrosssectionalimagingshowedcorrelationofthelocalizedperiostealthickeningwithglutealtuberosityprominenceatthe partialgluteusmaximusmuscleinsertionandthethirdtrochanter,previouslydescribedasafocalexcrescenceatthesuperiorgluteal tuberosity. Conclusion:NormalanatomicvariantsmaymimicprefracturefindingsofAFFinbisphosphonateanddenosumabnaïvepatients.These variantsincludeaprominentglutealtuberosityandthethirdtrochanter.Baseduponourresults,thesevariantscanbedifferentiated fromprefractureAFFfindingswithawidthlessthan3mmandlessthan3mmsubtrochantericdistance.Awarenessofthesevariants mayreducepatientanxiety,reducecostlyworkup,andhelpavoidunnecessarydelaysofbisphosphonateordenosumabtherapy. 70 Podium #38 MRARTHROGRAPHYOFTHEHIP:COMPARISONOFIDEALSPGRVOLUMESEQUENCETOSTANDARDMRSEQUENCESINTHE DETECTIONANDCHARACTERIZATIONOFACETABULARLABRALTEARS. JarrodDale;DonnaBlankenbaker;RichardKijowski;KirklandDavis;JamesKeene UniversityofWisconsin (Presentedby:JarrodDale,MD) Purpose:Tocomparethediagnosticperformanceofiterativedecompositionofwaterandfatwithechoasymmetryandleastsquares estimation(IDEAL)–spoiledgradientrecalledecho(SPGR)withthatofstandardmagneticresonance(MR)arthrographysequences fordetectingandcharacterizingacetabularlabraltearswithinthehipjoint. MaterialsandMethods:FollowingInstitutionalReviewBoardapproval,threemusculoskeletalradiologistsandonemusculoskeletal fellow retrospectively reviewed 87 consecutive hip MR arthrograms independently. IDEALSPGR images and the two dimensional routinefatsuppressedT1weightedMRarthrogramimageswereevaluatedatseparatesittings.Arthroscopicreportswereusedas thereferencestandardtoassessthesensitivityandspecificityofthetwoMRtechniquesfordetecting,localizing,andcharacterizing (partialthickness,fullthickness,complex)acetabularlabraltears.TheMcNemartestwasusedtocomparediagnosticperformance. InterobserveragreementwascalculatedusingunweightedCohen’skappa. Results:Ofthe87cases,atearwaspresentin79(90%).61(70%)patientswerefemaleand26(30%)weremale.53(87%)femaleshad atearand25(97%)maleshadatear.Averageageofallpatientswas36(range14–58yrs).Forallreadersandlocationscombined, thesensitivityandspecificityfordetectingthepresenceofanacetabularlabraltearwas97%and75%,respectively,forIDEALSPGR and98%and75%,respectively,forroutineMRarthrogramimages.Therewasnostatisticaldifferenceinaccuracybetweenthetwo setsofsequencesandnostatisticaldifferenceindetectionoflabraltearsbetweenthefourreadersusingeithertheIDEALSPGRor standard MRarthrographyprotocol. Labral tears involved the anterior superior quadrant(Q1) in97% ofcases,and there was no differenceintearlocalizationbetweenIDEALSPGRandstandardMRarthrogramforQ1tears.Interobserveragreementfordetecting thepresenceofalabraltearrangedfromfairtoexcellentanddidnotdifferbetweenthetwotechniques(Cohen’skappa0.38–0.90). Interobserveragreementonthetypeoflabraltearwaspoortofairanddidnotdifferbetweenthetwotechniques(Cohen’skappa 0.19–0.56). Conclusion: IDEALSPGR had similar sensitivity and specificity for detecting the presence and characterizing labral tears when comparedtotheroutineMRarthrogramprotocol.ThisimagingtechniquemaybeausefulpartofthehipMRexaminationtoreduce otherimagingplanesandoverallscantime. 71 72 Wednesday Wednesday, March 11, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 7:00a.m.–7:55a.m. ContinentalBreakfast 7:00a.m.–10:30a.m. ExhibitHallOpen 7:00a.m.–12:30p.m. Registration/InformationDeskOpen 7:00a.m.–10:30a.m. ePosterSession* *Asthissessionisnotmoderated,ePostersarenotCMEaccredited 8:00a.m.–10:00a.m. UPPEREXTREMITYSESSIONII Moderators:MikeTuite,MD;SoteriosGyftopoulos,MD 8:00a.m. #39 UltrasoundguidedFenestrationofTendonsabouttheHipandPelvis:ClinicalOutcomes JonJacobson;CorrieYablon (Presentedby:JonJacobson,MD) 8:20a.m #40 SuprascapularandSpinoglenoidNotchParalabralCystsandtheirAssociationwith SuprascapularNerveEntrapment JonMalone;HillaryGarner;JosephBestic;DanielWessell;JeffreyPeterson (Presentedby:JonMalone,MD) 8:40a.m. #41 "Enhancement"ofthecriticalzoneoftherotatorcuffonT1postarthrographicimages:marker fortendinosisandfalsepositivesignforarticularsurfacetears DarrenFitzpatrick;VivekJoshi;AlexMaderazo (Presentedby:DarrenFitzpatrick,MD) 9:00a.m. #42 ShearWaveUltrasoundElastographyEvaluationoftheSupraspinatusTendon StephanieHou;JamesBabb;AlexanderMerkle;RobertMcCabe;SoteriosGyftopoulos;RonaldS. Adler (Presentedby:StephanieHou,MD) 9:20a.m. #43 SonographicEvaluationoftheDistalBicepsTendon:AccuracyandPitfallsintheDiagnosisof PartialThicknessTears DanielSiegal;SamiKhan (Presentedby:DanielSiegal,MD) 9:35a.m. #44 Frequency,imagingfindings,riskfactorsandlongtermsequelaeofdistalclavicularosteolysis inyoungpatients FelixM.Gonzalez;MikaNevalainen;ChristopherC.Dodson;WilliamB.Morrison;AdamC.Zoga; JohannesB.Roedl (Presentedby:FelixGonzalez,MD) 9:50a.m. #45 CrackingtheCaseon"KnuckleCracking":TheSonographicEvidence Robert D. Boutin; Robert Szabo; Anuj Netto; David Nakamura; Cyrus Bateni; Michael Cronan; AbhijitJ.Chaudhari (Presentedby:RobertBoutin,MD) 73 Wednesday, March 11, 2015 GeneralSessionlocatedInArizonaBallroomunlessotherwisenoted. 10:05a.m.–10:10a.m. CASEOFTHEDAY: (Presentedby:JordanS.Gross,MD;BenjaminD.Levine,MD) 10:10a.m.–10:35a.m. Break–VisitExhibitHall TUMORII/OTHERSESSION Moderators:JeffPeterson,MD;KambizMotamedi,MD 10:30a.m.–12:30p.m. 10:30a.m. #46 18FFDGPET/CTasanIndicatorofSurvivalinBonePrimaryEwingSarcoma UsamaSalem;BehrangAmini;HubertChuang;NajatDaw;WeiWei;TamaraMinerHaygood;John E.Madewell;ColleenM.Costelloe (PresentedBy:UsamaSalem,MD) 10:50a.m. #47 MRIandclinicalfeaturesofLangerhansCellHistiocytosis(LCH)inthepelvisandextremities: CanLCHreallylooklikeanything? JonathanSamet;LauraM.Fayad (PresentedBy:JonathanSamet,MD) 11:10a.m. #48 EnhancedDetectionofCTOccultBoneMarrowLesionsintheLumbarSpineusingTrabecular Suppression JoshuaM.Polster (Presentedby:JoshuaPolster,MD) 11:30a.m. #49 WholebodyAnatomic,FunctionalandMetabolicImagingCharacteristicsofPeripheralLesions inPatientswithSchwannomatosis ShivaniAhlawat;AsadBaig;JaishriBlakeley;MichaelA.Jacobs;LauraMFayad (Presentedby:ShivaniAhlawat,MD) 11:45a.m. #50 Myxofibrosarcoma:Imagingappearanceatpresentationandpatternsoflocalfailure CoreyDaniels;BehrangAmini (PresentedBy:CoreyDaniels,MD) 12:00p.m. #51 IMAGINGCHARACTERISTICSOFINTRAVASCULARPAPILLARYENDOTHELIALHYPERPLASIA KeithCraig;EduardoEscobar;MarkKransdorf (Presentedby:KeithCraig,MD) 12:15p.m. #52 ONSITEULTRASOUNDEVALUATIONOFHYPERACUTELOWEREXTREMITYMUSCLEINJURIESIN PROFESSIONALFOOTBALLPLAYERS:PRELIMINARYEXPERIENCE RichardE.A.Walker;ShamirPatel;SarahL.Koles;SteveR.Poplawski;JamesThorne;IanJ.Auld; JamesI.Stewart;JamesR.MacKenzie (Presentedby:RichardWalker,MD) 74 Related ePosters FullePosterAbstractsareonPage165 UpperExtremityII ePoster#38 CONCEPTSOFOPERATIVETREATMENTINSCAPHOLUNATEINSTABILITY:ANIMAGING PERSPECTIVE KimiaKKani;HyojeongMulcahy;FelixS.Chew UniversityofWashington,Seattle ePoster#39 MRIMAGINGOFSOFTTISSUEINJURIESOFTHEFINGERS KimiaKKani;HyojeongMulcahy;FelixS.Chew UniversityofWashington,Seattle ePoster#40 COSTOCHONDRALINJURIES:HOWNOTTOMISSIT! ManickamKumaravel;NicholasBeckmann;SusannaSpence;UsmanAnwer UniversityofTexas,Houston TumorII/Misc ePoster#41 SONOGRAPHYOFORTHOPEDICHARDWARECOMPLICATIONS JonellePetscavageThomas;CristyGustas PennState ePoster#42 DEBUNKINGTHEMYTHSOFGOUT SayedAli;StephenLing;IreneTan;AnneMarieSchorpion Temple ePoster#43 NANOFRACTURES:ALLYOUWANTEDTOKNOW! ManickamKumaravel;NicholasBeckmann;SusannaSpence UniversityofTexas,Houston ePoster#44 SECRETSOFTHEPERIOSTEUM:CLUESTOUNDERLYINGOSSEOUSANDMETABOLICDISEASES ChuanxingQu;VincentLeeMD,AndrewCordle;CynthiaABritton UniversityofPittsburghMedicalCenter ePoster#45 PITFALLSINCERVICALSPINECTINTHETRAUMAPATIENT JoesphLivingston;JohnBoardman;AndrewWilmot;CarolL.Andrews UniversityofPittsburghMedicalCenter ePoster#46 BACKPAININCHILDRENANDYOUNGADULTS:BEYONDSPONDYLOLYSIS ShefaliKothary;DarrylSneag;DouglasMintz;YoshimiEndo HospitalofSpecialSurgery ePoster#47 FACINGTHEFACTS:USINGPATTERNRECOGNITIONTOMAKEFACIALCTEASY SusannaC.Spence UniversityofTexas,Houston ePoster#48 MAGNETIC RESONANCE IMAGING FINDINGS OF PERIPHERAL NERVES IN CHARCOTMARIE TOOTH SangeetaChaudhary;JonellePetscavageThomas;StephanieABernard;EricAWalker HersheyMedicalCenter 75 Related ePosters FullePosterAbstractsareonPage165 ePoster#49 SCHWANNOMATOSIS:REVIEWOFIMAGINGANDCLINICALFEATURESINARECENTLY RECOGNIZEDENTITY ShivaniAhlawat;AsadBaig;JaishriBlakeley;MichaelA.Jacobs;LauraMFayad JohnsHopkinsUniversity ePoster#50 TRAUMATICNEUROMAS:COMMONMRIFEATURES ShivaniAhlawat;AllanJBelzberg;ElizabethMontgomery;LauraMFayad JohnsHopkinsUniversity 76 Podium #39 ULTRASOUNDGUIDEDFENESTRATIONOFTENDONSABOUTTHEHIPANDPELVIS:CLINICALOUTCOMES JonJacobson;CorrieYablon UniversityofMichigan (Presentedby:JonJacobson) Purpose:Percutaneousultrasoundguidedtendonfenestrationhasbeenusedtotreattendinopathyoftheelbow,knee,andankle withpromisingresults.Thepurposeofthisstudyistoevaluatetheclinicaloutcomeofultrasoundguidedfenestrationoftendons aboutthehipandpelvis. MaterialsandMethods:AfterInstitutionalReviewBoardapproval,retrospectivesearchofradiologyimagingreportsfromJanuary1, 2005toJune30,2011wascompletedtoidentifypatientswhoweretreatedwithultrasoundguidedtendonfenestrationaboutthe hiporpelvis.Subsequentclinicnoteswereretrospectivelyreviewedtodetermineifthepatientshowedmarkedimprovement,some improvement,nochange,orworseningsymptoms. Results:Thestudygroupconsistedof22tendonsin21patientswithanaverageageof55.8years(range26.7–77.0years).The treatedtendonsincluded11gluteusmedius(9tendinosis,2partialtear),twogluteusminimus(bothtendinosis),eighthamstring(6 tendinosis,2partialtear),and1tensorfascialatae(tendinosis).Theaveragetimeintervaltoclinicalfollowupwas70days(range7– 813days).Therewasmarkedimprovementin45.5%(10/22),someimprovementin36.4%(8/22),nochangeinsymptomsin9.1% (2/22) and worsening symptoms in 9.1% (2/22). There were no patient variables (age, duration of symptoms, gender, tendon, tendinosisversustear,priorphysicaltherapy,priorcorticosteroidinjection)thatweresignificantlydifferentbetweenpatientswho improvedandthosewhodidnot. Conclusion:Clinicalfollowupafterultrasoundguidedfenestrationofthegluteusmedius,gluteusminimus,proximalhamstring,or tensorfascialataetendonsshowedthat82%ofourpatientshadimprovementintheirsymptoms. 77 78 Podium #40 SUPRASCAPULARANDSPINOGLENOIDNOTCHPARALABRALCYSTSANDTHEIRASSOCIATIONWITHSUPRASCAPULARNERVE ENTRAPMENT JonMalone;HillaryGarner;JosephBestic;DanielWessell;JeffreyPeterson MayoClinicFlorida (Presentedby:JonMalone) Introduction: To assess the prevalence of suprascapular nerve entrapment associated with paralabral cysts located in the suprascapularorspinoglenoidnotches. Materials and Methods: The radiology information system (RIS) database was queried to identify all shoulder MR exams from 09/01/1998 to 09/10/2014 (n=16,262). Associated reports were then queried for the terms “suprascapular,” “spinoglenoid,” and “notch,”aswellasvariants.380examswereidentifiedandweresubsequentlyevaluatedforthepresenceofparalabralcystsineither thespinoglenoidorsuprascapularnotch.Patientswithconcomitantrotatorcufftearswereexcluded.Imageswereevaluatedforcyst location, cyst size, and presence or absence of suprascapular nerve entrapment. Cysts were assumed to be ellipsoid in shape for volumeestimation.Diagnosticcriteriaforsuprascapularnerveentrapmentconsistedofaparalabralcystwithinthesuprascapular notch,thespinoglenoidnotch,orbothwithcoincidentatrophyand/oredemaofthesupraspinatusorinfraspinatusmusculatureand anintactrotatorcuff.Statisticalanalysiswasperformedtodeterminetherelativeriskratioofnerveentrapmentrelatedtobothcyst locationandvolume. Results: Among 16,262 exams, 125 paralabral cysts (0.76% incidence) were found in either the suprascapular notch (n=31), the spinoglenoidnotch(n=63),orboth(n=19).Twelveexamswereexcludedduetoconcomitantfullthicknessrotatorcufftears.Fourteen (14%)oftheremaining113examsdemonstratedcystswithassociatedchangesofnerveentrapment.Eightofthe63(13%)isolated spinoglenoidnotchcystswereassociatedwithnerveentrapmentchanges,exclusivelyoftheinfraspinatusmuscle.Oneofthe31(3.2%) isolated suprascapular cysts was associated with nerve entrapment changes, involving both the supraspinatus and infraspinatus muscles.Fiveofthe19(26%)cystsencompassingbothnotcheswereassociatedwithnerveentrapmentchanges,eitherinvolvingthe supraspinatus(n=1,5.2%),theinfraspinatus(n=2,10.4%),orboth(n=2,10.4%).Cystsspanningbothnotcheswere8.2timesmore likelytocausenerveentrapmentthancystsisolatedtothesuprascapularnotch(p=0.02),andwere2.1timesmorelikelythancysts isolatedtothespinoglenoidnotch,althoughthisdidnotreachsignificance(p=0.14).Cystsinthespinoglenoidnotchwere3.9times morelikelytocausenerveentrapmentthancystsinthesuprascapularnotch,althoughthisalsodidnotreachsignificance(p=0.14). Cysts>5mL(n=18,16%)were4.0timesmorelikelytocausenerveentrapment(p=0.01).Amongnoncysticlesions(n=13)thatinvolved eithernotch,allseven(100%)metastaseswereassociatedwithnerveentrapmentchanges,aswerethesingularcasesoffracture, infection and loose body. Only one of 16 (6.3%) varices, one of three (33%) hardware cases and one of two (50%) lipomas were associatedwithnerveentrapment. Conclusion: Suprascapular or spinoglenoid notch paralabral cysts are infrequent. Coincident MR evidence of nerve entrapment is uncommonbutmoreprevalentwithlargecyststhatspanboththesuprascapularandspinoglenoidnotches. 79 Podium #41 ‘ENHANCEMENT’OFTHECRITICALZONEOFTHEROTATORCUFFONT1POSTARTHROGRAPHICIMAGES:MARKERFOR TENDINOSISANDFALSEPOSITIVESIGNFORARTICULARSURFACETEARS DarrenFitzpatrick;VivekJoshi;AlexMaderazo MountSinaiMedicalCenter (Presentedby:DarrenFitzpatrick) WeretrospectivelyreviewedMRarthrogramswithdilutegadoliniumperformedatourinstitutionbetweenJan.2009andOctober 2013. Of these 213 exams, 55 had arthroscopic correlation. Coronal proton density, T2Fs and T1FS images were reviewed in concordance2musculoskeletalradiologiststoevaluatetheamountoftendonenhancementonT1FSimages.Theseverityoftendinosis andthepresenceoftendontearingwereevaluatedonconventionalcoronalsequences(protondensityandT2FS).IRBapprovalwas obtained. Five cases of nonenhancing tendons were identified all of which were characterized as normal on conventional sequences and arthroscopy.Allcasesoftendonenhancementoccurredinthecriticalzoneofthecuff,distaltotherotatorcableandproximaltothe footprint. Ofthe22casesofmildenhancement(25%orlessoftendonthickness),21wereclassifiedashavingnoormildtendinosis.One,low gradetearwasreportedonarthroscopyinthiscohort,whichwasconcordantonbothT1FSandconventionalimages. Ofthe9casesofmoderatetendonenhancement(2550%),7caseswerereportedasmoderatetendinosiswith3mild,arthroscopy provenarticularsurfacetears,2ofwhichwerereportedonMRI. Ofthe7casesofsignificanttendonenhancement(50100%),5werecharacterizedasseveretendinosis,1asmoderatetendinosis. One case of mild tendinosis was identified which also demonstrated full thickness tendon tearing. One additional tear was characterizedonarthroscopy,whichwasconcordantwiththeMRfindings. Ofthe10casesofarthroscopyproventendontearinginourcohort,3caseshadconcordantimagingfindingsonT1FSimagesand conventionalsequences,withlocationanddegreeoftendonenhancementmatchingthesitesoftearingonconventionalsequences. These were corroborated with arthroscopy. Five cases had T1 enhancement larger than the corresponding tendon tear on conventional sequences. Two cases of mild articular surface tearing were identified at arthroscopy which were not noted on MR sequences.TwoadditionalcasesoftearingwerereportedonMRimageswhichwerenotmentionedinthearthroscopyreport. ThefindingsofourpreliminaryresultssuggeststherearesomeconfoundingfactorsinvolvedinreviewingT1FSimagesoftherotator cuffonMRarthrography.Increasedsignal(“enhancement”)ofthetendonundersurfaceisacommonfindinginthecriticalzoneand shouldnotbeconfusedfortendontearing.Theamountoftendonenhancementdoescorrelatewiththedegreeoftendinosis.This maybetheresultofincreasedpermeabilityofthecriticalzonefiberstogadolinium.Furthermore,evaluationofcaseswithtendon tears demonstrates enhancement of the proximal tendon fibers out of proportion to signal abnormality of the tendon tear on conventional (proton density, T2FS) imaging sequences, suggesting the presence of abnormal, intact tendon fibers at the site of tearing. 80 Podium #42 SHEARWAVEULTRASOUNDELASTOGRAPHYEVALUATIONOFTHESUPRASPINATUSTENDON StephanieHou;JamesBabb;AlexanderMerkle;RobertMcCabe;SoteriosGyftopoulos;RonaldS.Adler NYULangoneMedicalCenter (Presentedby:StephanieHou) Purpose:Todemonstratethatsonographicmorphologicpropertiesofthesupraspinatustendoncorrelatewithmechanicalproperties, asassessedquantitativelybyshearwaveultrasoundelastography. Materials and Methods: This retrospective study included 36 patients who underwent sonographic evaluation of one or both shoulders on one or multiple dates from June 2013 through October 2014. A shoulder was excluded if the supraspinatus tendon containedcalcificationsorhadundergonesurgicalrepairforatear.Eachsonographicevaluationofeachshoulderwasregardedasa separatedatapoint,totaling76sonographicevaluationsof36patients.Foreachsonographicevaluation,themorphologicappearance oftheproximalanddistalsupraspinatustendonwasgraded(1=normalormildtendinosiswithoutatear,2=moderateorsevere tendinosiswithoutatear,3=partialtear,4=fullthicknesstear)byconsensusof2musculoskeletalradiologists.Inaddition,foreach sonographicevaluation,samplevolumeswererandomlyplacedwithintheproximalanddistalsupraspinatustendon,viewedinthe longitudinaldimension,toobtainshearwaveultrasoundelastographymeasurements.Finally,for68ofthesonographicevaluations, onthesameimageusedforsamplevolumesofthesupraspinatustendon,samplevolumeswererandomlyplacedwithinthedeltoid muscletoobtainshearwaveultrasoundelastographymeasurements.Spearmanrankcorrelationsassessedtheassociationbetween tendonmorphologygradeandelastographymeasurements.MannWhitneytestscomparedelastographymeasurementsbetween scans grouped by symptomatology or morphology grade. Bootstrap resampling procedures accounted for lack of statistical independenceamongscansofthesamepatient. Results:Ofthe36patients,therewere21malesand15females(meanage46,range2374).Ofthe76sonographicevaluations,there were38malesand38females(meanage44,range2374),36rightand40leftshoulders,and21symptomaticand55asymptomatic shoulders.Thetendonmorphologygradeandelastographymeasurementswerecorrelatedinboththeproximal(p<0.001)anddistal (p=0.002)supraspinatustendon.Comparingbetweengrade1andgrade2morphology,theelastographymeasurementsdiffered significantlyinboththeproximal(p=0.001)anddistal(p=0.012)supraspinatustendon.Comparingbetweengrade2andgrade>2 morphology, the elastography measurements also differed significantly in both the proximal (p = 0.002) and distal (p = 0.004) supraspinatustendon.Interestingly,deltoidmuscleelastographymeasurementsalsowereassociatedwiththemorphologygradeof the proximal (p = 0.004) and distal (p = 0.007) supraspinatus tendon; this measurement also differed significantly between asymptomaticandsymptomaticscans(p=0.001). Conclusion:Thesonographicmorphologicpropertiesofthesupraspinatustendoncorrelatewithmechanicalproperties,asassessed byshearwaveultrasoundelastography.Thesefindingsindicatethatshearwaveultrasoundelastography–anoninvasive,relatively inexpensive, and simple examination – can provide an objective measurement of tendon elasticity. Correlation of deltoid muscle elasticitywithsupraspinatustendonmorphologyandsymptomatologymayberelatedtothetwomusclesbeingaforcecouple.Further researchisneededtoassesswhethertendonelastographymeasurementscorrelatewiththeMRImorphologicappearanceofthe tendonandwithintraoperativeevaluationoftendonquality. 81 Podium #43 SONOGRAPHICEVALUATIONOFTHEDISTALBICEPSTENDON:ACCURACYANDPITFALLSINTHEDIAGNOSISOFPARTIALTHICKNESS TEARS DanielSiegal;SamiKhan HenryFordHospital (Presentedby:DanielSiegal) Thepurposeofthisinvestigationwasdescribethesonographicfindingsanddiagnosticpitfallsofpartialtearsinvolvingthedistalbiceps brachiitendon,andtoinvestigatethediagnosticaccuracyofultrasoundwhenpartialtearisdiagnosedorthesonographicfindings regardingtearareinconclusive. Thirtyfourpatients(30male,4female;averageage50years)withdiagnosisofpartialtearorinconclusivediagnosticexaminationof the distal biceps tendon were retrospectively identified, and imaging and clinical following was reviewed. Concordance between ultrasoundfindingsofpartialtearandclinicalexamwaslow.MRIfollowupwasrecommendedineight(24%)andMRIwasultimately performedin11cases(32%).Twentypatients(59%)wentontohavesurgery,andthemajorityofthesecaseswerefoundtohave completetears.Despitetheinitialultrasounddiagnosis,onlythreecases(15%)werefoundtohavepartialtearsattimeofrepair,and allofthesewerereportedtobehighgradetearsinvolvingatleast80%oftendonfibers. Pitfallsinthediagnosisofpartialdistalbicepstendontearincludemalpositioningofthetransducer,mistakingthebrachioradialis tendonforthedistalbicepstendon,hemorrhagicdebriswithinthedistalbicepstendonsheathandothermimickersofnormaltendon fibers,anddifficultyrecognizingvariabletearmorphologiesanddegreesofretraction. Althoughultrasoundhasbeendemonstratedtobeanaccuratediagnostictoolfordiagnosisofdistalbicepstendontears,radiologists andsonographersshouldbeawareofthechallengesandpitfallsthatarisewhenthediagnosisofpartialtendonteariscontemplated. 82 Podium #44 FREQUENCY,IMAGINGFINDINGS,RISKFACTORSANDLONGTERMSEQUELAEOFDISTALCLAVICULAROSTEOLYSISINYOUNG PATIENTS. FelixM.Gonzalez;MikaNevalainen;ChristopherC.Dodson;WilliamB.Morrison;AdamC.Zoga;JohannesB.Roedl ThomasJeffersonUniversityHospital (Presentedby:FelixM.Gonzalez) Objective:Atraumaticdistalclavicularosteolysis(DCO)hasbeendescribedinadultmaleweightlifters.Ourpurposewastoinvestigate thefrequency,magneticresonanceimaging(MRI)characteristics,riskfactorsandlongtermsequelaeofDCOinyoungpatients. MaterialsandMethods:IndividualswithatraumaticDCOwereidentifiedinaretrospectivereviewof1432consecutiveMRIshoulder reportsinpatientsbetween13and19yearsofage.MRIfindingsofDCO,associationwithathleticactivity,shorttermclinicaloutcome after36monthsandlongtermclinicalandMRIoutcomeafter2yearswereanalyzed.ApreMRIquestionnaireassessedthepatients’ athletichistoryincludingoverheadactivityandweightlifting. Results:Atameanageof15.9years,6.5%(93/1432)ofpatientshadatraumaticDCOand24%werefemales.Thecombinationofan overheadsport(basketball,volleyball,tennis,swimming)andsupplementalweighttrainingwasariskfactorforDCO(Oddsratio=38, p=0.01).93%ofpatientsrespondedtoconservativetherapy.Onfollowupimaging,71%ofDCOpatientshadacromioclavicular(AC) jointosteoarthritis(vs.35%incontrols,p=0.006),79%hadflatteningofthedistalclavicleandintervalwideningoftheACjointtoa mean of 5.0 mm (compared to 2.4 mm in controls, p<0.001). Severity of DCO edema was associated with pain (p<0.02) at initial presentationandwithACjointosteoarthritis(p=0.004)onfollowup. Conclusion:Inteenagers,thecombinationofweightliftingandoverheadactivityisariskfactorforatraumaticDCOandfemalesare affectedin24%.LongtermsequelaeincludewideningoftheACjointandACjointosteoarthritis. Fig.1–Gradingofatraumaticdistalclavicularosteolysis(DCO).A.GradeIDCO;B.GradeIIDCO;C.GradeIIIDCO. Fig.2–Intervalwideningoftheacromioclavicular(AC)jointonfollowupimagingofapatientwithdistalclavicularosteolysis(DCO).A. GradeIIDCOandanACwidthof3.3mm.B.Samepatient(asinA)presented4yearsand9monthslaterwithwideningoftheACjoint tonow6.7mm(intervalwidening:3.4mm)andearly(gradeI)osteoarthritiswithsmallmarginalosteophytesattheACjoint. Fig.3–Intervalwideningoftheacromioclavicular(AC)jointonfollowupimagingofapatientwithdistalclavicularosteolysis(DCO).A. GradeIIDCOandanACwidthof2.9mm.B.Samepatient(asinA)presented4yearsand6monthslaterwithwideningoftheACjoint tonow9.1mm(intervalwidening6.2mm)andearly(gradeI)osteoarthritiswithsmallmarginalosteophytesattheACjoint. Fig.4–Nointervalchangeinacromioclavicular(AC)jointwidthonfollowupimagingofapatientfromthecontrolgroup. 83 84 85 Podium #45 CRACKINGTHECASEON“KNUCKLECRACKING”:THESONOGRAPHICEVIDENCE RobertD.Boutin;RobertSzabo;AnujNetto;DavidNakamura;CyrusBateni;MichaelCronan;AbhijitJ.Chaudhari UCDavis (Presentedby:RobertD.Boutin) INTRODUCTION:Inthemetacarpophalangealjoint(MPJ)regionofthehand,audibleemissionsmaybeassociatedwithabroadarray of extraarticular and intraarticular conditions. With voluntary knuckle cracking (KC) in asymptomatic individuals, a leading theory postulatesthatsoundgenerationiscausedbyfluidcavitation,butthistheoryishotlydebated.(Thestudycommonlycitedasevidence forcavitationwasbasedonKCinonly5subjects,usingsequentialXrayexposuresduringmechanicalloadingofupto16kg[Unsworth 1971].)Toourknowledge,dynamicimagingduringactivemotionhasnotbeenusedtostudyKCwithoutionizingradiation. OBJECTIVES:To:1)reportthestaticanddynamicsonographicappearanceofKC;2)analyzetheperformanceofsonographyforthe diagnosisofKC;and3)calculatethetemporalrelationshipandKCdurationofanytransientintraarticularprocessduringsonography. METHODS:Aprospective,IRBapprovedstudywasperformedonhealthyadultsubjectswithandwithoutahistoryofhabitualKC. (Exclusioncriteriawereahistoryofpainorarthritisinthehands.)TheclinicalhistoryincludedKCeventsperdaymultipliedbythe numberofKCyears(allowingthecalculationof“crackyears”)andaQuickDASHquestionnaire.Physicalexamination,includinggrip strengthandBeightonscoring,wasperformedbytwosubspecialtyorthopaedists(blindedtosubjectKChistory).Sonography(with temporalresolutionof87frames/sec)wasconductedbyasinglesonographer,withstaticandcineimagesrecordedbefore,during, and after MPJ distraction was performed by the subjects; any audible “crack” during the distraction maneuver was recorded separately.TwoblindedmusculoskeletalradiologistsinterpretedtheimagesforadefinitehyperechoicfocusduringandafterMPJ distraction(notpresentpriortodistraction);thiswascomparedagainstthereferencestandardofanaudible“crack”duringjoint distraction.Thesonographicdurationofanyhyperechoicflashinthejointwasrecordedbycountingthenumberofrelevantcine frames. RESULTS:Westudied130MPJsof13subjects(8women,5men),withmeanageof32years(range,1863).Incomparing6nonKC subjects(with0“crackyears”)versus7KCsubjects(with“crackyears”rangingfrom16to800),therewasnosignificantdifferencein sex,age,QuickDASHscore,gripstrength,orBeightonscore.In17ofthe26MPJswithanaudible“crack”,blindedreadersobserveda definitehyperechoicfocusappearinthejoint.Sonographicreadershada94%specificityand88%accuracy.Oncineimaging,abrilliant hyperechoicflashwasparticularlycharacteristic,occurringsimultaneouslywiththeKCeventandlastingapproximately115msec. CONCLUSION:SonographicexaminationduringactivemovementoftheMPJscanshowdistinctivefindingsofKCwithrelativelyhigh specificity and accuracy. The sonographic features corroborate the theory of cavitation as the etiology for sound generation in voluntaryKC. 86 Podium #46 18FFDGPET/CTASANINDICATOROFSURVIVALINBONEPRIMARYEWINGSARCOMA UsamaSalem;BehrangAmini;HubertChuang;NajatDaw;WeiWei;TamaraMinerHaygood;JohnE.Madewell;ColleenM.Costelloe TheUniversityofTexasM.D.AndersonCancerCenter (Presentedby:UsamaSalem) Purpose:Theexistingliteratureof18FFDGPET/CTinEwingsarcomainvestigatespopulationsofpatientswithbothsofttissueand boneprimarytumors.Theaimofourstudywastoevaluatewhether18FFDGPET/CTusingthemaximumstandardizeduptakevalue (SUV (max)) before and after initiation of chemotherapy, can be used as an indicator of survival in patients with Ewing sarcoma originatingonlyinbone. MaterialsandMethods:Aretrospectivedatabasesearchwasconductedfrom20042011and178patientswithpathologicallyproven boneprimaryEwingsarcomawereidentified.PatientswhoreceivedtreatmentbeforetheinitialPET/CTorunderwentPET/CTatother institutions were excluded. Twentynine patients underwent 18 FFDG PET/CT before and after starting chemotherapy at our institution.Thestudyincluded10femalesand19males,withamedianageof18years.Onepatientwasexcludedfromtheanalysis duetopartialtumorresectionbeforetheinitialPET/CT.Medianfollowuptimeforpatientsalivewas6.2years(range:2.69.8years). UnivariateCoxproportionalhazardmodelwasusedtoassesseffectsofbaselineSUV(max),postchemoSUV(max),andthechange ofSUV(max)onoverallsurvival(OS)andprogressionfreesurvival(PFS). Results:MedianSUV(max)was8.9forbaselineand3.2postchemotherapy.AhighSUV(max)before(HR=1.05,95%CI:1.01.1,P= 0.01) and after (HR =1.2, 95% CI: 1.01.4, P = 0.01) chemotherapy was associated with worse overall survival. Optimal cut points SUVmaxhigherthan11.55beforechemotherapywasassociatedwithworseoverallsurvivalandprogressionfreesurvival.Baseline SUVmaxhigherthan11.55hadsignificantlyworseOS(HR=5.71,95%CI:1.85–17.61,pvalue=0.003)andPFS(HR=3.16,95%CI: 1.13–8.79,pvalue=0.03)comparedtothosewithlowerSUVmax.NosignificantpostchemotherapycutpointsforSUV(max)were identified. Conclusion:BaselineandpostchemotherapySUV(max)canbeusedasaprognosticindicatorforoverallsurvivalinboneprimary Ewingsarcoma. 87 Podium #47 MRIANDCLINICALFEATURESOFLANGERHANSCELLHISTIOCYTOSIS(LCH)INTHEPELVISANDEXTREMITIES:CANLCHREALLY LOOKLIKEANYTHING? JonathanSamet;LauraM.Fayad LurieChildrensHospital (Presentedby:JonathanSamet,MD) BACKGROUNDANDPURPOSE:LangerhansCellHistiocytosis(LCH)isararedisorder,butoftendiagnosedinchildren,thatcanaffect a variety of organ systems including bone, lungs, liver, and spleen. When LCH involves the skull or spine it produces a nearly pathognomonic imaging appearance. However, at initial presentation in the pelvis or extremities, MRI is performed routinely. Reportedly,LCHcanappearhighlyaggressivebyMRI,andisoftenmisdiagnosedassarcomaorinfection.Conversely,radiologistsare taughtthatLCHcanmimicanybonelesion.ThepurposeofthisstudyistocomprehensivelyassessclinicalandMRIfeaturesofLCH whenitsinitialpresentationisthatofanapparentlyisolatedskeletallesion. METHODSANDMATERIALS:ThisIRBapprovedretrospectivestudyreviewiedtheMRIandclinicalfeaturesof12pathologicallyproven casesofLCHinvolvingthepelvisandextremities.Onefellowshiptrainedradiologistreviewedthe12MRIstudiesandevaluatedthe lesions for multiple characteristics (location, size, T1/ T2 features, degree of postcontrast enhancement (mild, moderate, pronounced),perilesionalboneandsofttissuesignal,endostealscalloping,periostealreaction,softtissuemass,pathologicfracture). Demographiccriteriaandprebiopsyradiologicdiagnoseswerecollectedfromtheoriginalclinicalreports.Erythrocytesedimentation rate(ESR),Creactiveprotein(CRP),temperature,whitebloodcellcount(WBC),andpresenceofpain,werecollectedatthetimeof diagnosiswhenavailable.Descriptivestatisticswerereported. RESULTS:ThesepreliminaryresultsfromalargerstudyonLCHshowedlocationsofLCHtoincludehumerus(n=4),femur(n=3),iliac (n=3), tibia (n=1), and scapula (n=1). Age of patients ranged from 112 years old. Size ranged from 2.57.1 cm. All lesions were hyperintenserelativetomuscleonT1andT2weightedsequences.Alllesionsdemonstratedperilesionalbonemarrowandsofttissue edema, endosteal scalloping, periosteal reaction, and postcontrast enhancement (17% mild, 42% moderate, 42% pronounced). Averagelengthofperilesionalmarrowedemawas5.1cm.In10/12(83%)lesions,anassociatedsofttissuemassextendingbeyond the osseous cortex was found, with size range of 0.7 4.4 cm. No lesions were associated with a pathologic fracture. At initial presentation,LCHwastheleadingdiagnosisinonly2/12(16%)andnotconsideredin6/12(50%)cases.Malignancyandinfectionwere consideredinthedifferentialdiagnosisin8/12(66%)and9/12(75%)respectively;osteomyelitiswastheonlydiagnosisgivenin3/12 (25%).TheWBC,ESRandCRPwereelevatedin2/12(16%),6/8(75%)and2/8(25%)ofcasesrespectively.Nofeverwasrecordedin availablecases(0/7)andpainwasreportedin9/10(90%). CONCLUSION:ClinicalfeaturesofLCHinthepelvisandextremitiesoverlapwithinfectionandmalignancy,butLCHmustbeconsidered inthedifferentialdiagnosis,asitroutinelypresentswithaggressiveMRIfeatures,includingendostealscalloping,periostealreaction, perilesionaledemaandasofttissuemass.Furthermore,anunknownskeletallesionatpresentationwithoutaggressivefeaturesis unlikelytorepresentLCH. 88 Podium #48 ENHANCEDDETECTIONOFCTOCCULTBONEMARROWLESIONSINTHELUMBARSPINEUSINGTRABECULARSUPPRESSION JoshuaM.Polster ClevelandClinicFoundation (Presentedby:JoshuaM.Polster) Background/objective:ComputedTomography(CT)isknowntobelesssensitiveforthedetectionofbonemarrowlesionsrelativeto MRIduetoitslowersofttissuecontrast.Apostprocessingtechniquehasbeendevelopedtoenhancesofttissuecontrastofthebone marrowbysuppressingthecontributionoftrabecularbonetothefinalimage.Thepurposeofthisstudyistoassessthistechniquein aseriesofclinicalexamplesofnoncontrastCTofthelumbarspine. MaterialsandMethods:Softwareencodingthetrabecularsuppressionalgorithmwasdeveloped.Animagingphantomfortrabecular bone with an internal lesion was created and scanned with CT (Siemens Definition). The trabecular suppression algorithm was employedtodemonstrateproofofconcept.Areviewofmedicalrecordsfrom1/2008to3/2013wasthenperformedtoidentifyall casesofnoncontrastCTofthelumbarspineperformedwithin3monthsofMRIofthelumbarspine.MRIswerereviewedbyone musculoskeletalradiologisttodeterminethepresenceorabsenceofbonemarrowreplacinglesions.Forthosewithsuchlesions,the corresponding CT reports were reviewed to determine if the lesion was seen upon initial interpretation. For those CTs without a concordantlesionidentified,thetrabecularsuppressionalgorithmwasperformedandtheimageswereevaluatedforthepresenceof acorrespondingbonemarrowlesion. Results:Atotalof182caseswereidentified.73/182caseshadbonemarrowlesionsidentifiedonMRI.56/73hadconcordantlesions onnoncontrastCT(77%),17/73hadoccultbonemarrowlesionsonCT(23%).Ofthese,2caseshadbeengivencontrastand4cases didnothaveadequatethroughplaneresolutiontoperformthealgorithm;thesecaseswereexcludedfromfurtherevaluation.Ofthe remaining11cases,8/11(73%)hadconcordantlesionsidentifiedfollowingtheuseofthetrabecularsuppressionalgorithm.Lesions includedmetastaticnonsmallcelllungcancer,metastaticrectal,renalandbreastcancerandanatypicalhemangioma. Conclusion:ThetrabecularsuppressiontechniqueallowedidentificationofoccultbonelesionsonnoncontrastlumbarspineCTin8 of11cases. 89 Podium #49 WHOLEBODYANATOMIC,FUNCTIONALANDMETABOLICIMAGINGCHARACTERISTICSOFPERIPHERALLESIONSINPATIENTS WITHSCHWANNOMATOSIS ShivaniAhlawat;AsadBaig;JaishriBlakeley;MichaelAJacobs;LauraMFayad JohnsHopkinsUniversity (Presentedby:ShivaniAhlawat) OBJECTIVES: Schwannomatosis (SWN) is a recently recognized syndrome characterized by the development of peripheral schwannomas,reportedlyintheabsenceofvestibularschwannomas.WholebodyMRI(WBMRI)and18FFDGPET/CTareusedinthe managementofpatientswithneurofibromatoses.Thepurposeofthisstudyistodescribetheanatomic,functionalandmetabolic characteristicsofperipheralnervesheathtumors(PNSTs)inpatientswithSWNonWBMRI(withanatomicandfunctionalimaging) andFDGPETimaging(metabolicimaging). METHODS: WBMRIs performed in 13 subjects with clinically and/or geneticallyproven SWN using STIR, T1weighted, contrast enhancedT1weighted,anddiffusionweightedimaging(DWI)withapparentdiffusioncoefficient(ADC)mappingwereretrospectively reviewed.Sixsubjectshad17serialWBMRIs(rangeoffollowupfrom3to41months)andtwosubjectsunderwent18FFDGPET/CT. Tworeadersreviewedallimagingforthepresence,andcharacterofperipherallesions.Lesionsizeandfeatures(plexiformvssolitary, signalintensity,heterogeneity,postcontrastenhancementcharacteristics,ADCvalues,standardizeduptakevalues(SUVmax))were recorded.Ancillaryfindingswerealsorecorded.Descriptivestatisticswerereported.SubjectswithserialWBMRIswereassessedfor changestolesionsizeandimagingfeatures. RESULTS:Of13subjects,23%(3/13)hadWBMRIat1.5Twhile77%(10/13)at3Tinitially.Atotalof255lesionsweredetectedand 153indexlesionswerecharacterized,withaveragesizeof3cm.Lesionswerecharacterizedastumors(97%(149/153))orcysts(3% (4/153))basedoncontrastenhancementproperties.ThemajorityofPNSTsweresolitary(96%(143/149))whileonly4%(6/149)were plexiform. OnT1, tumors were homogeneously isointense ((99%)148/149); onSTIR, tumors were predominantly heterogeneously hyperintense ((81%)121/149); on postcontrast T1, tumors enhanced homogeneously ((19%) 23/123) or heterogeneously ((81%) 100/123);onDWI,tumorADCvalues(×103mm2/s)werevariable(minimum1.4+0.4andaverage,2+0.4);suggestingvariabilityin the tumor microenvironment. Of 15 lesions assessed by PET, the average SUVmax was 5.7 and8.6 on early and delayed imaging respectively.SerialMRIsshowedstablelesionsin3subjectsandanincreaseinlesionsizein3subjects.InonePNST,(1%(1/149)), malignantdegenerationwasidentifiedbysizechangeandsuspiciousfunctionalcharacteristics(increaseinsizefrom8.7cmto9.6cm, decreaseinminimumADCvaluesfrom1.4to0.4,andincreaseinSUVmaxfrom6to9.6)andsubsequentlyhistologicallyproven. Ancillary findings on WBMRI included nerve root thickening (23% (3/13)), spinal canal lesions (15% (2/13)) and the absence of scoliosis. CONCLUSION:TheimagingfeaturesofSWNincludeperipheralnervethickening,intraspinallesionsandbenignPNSTswithvariable characteristics,notablyheterogeneousanatomicfeatures,variablebuthighADCvaluesandhighmetabolicactivitybyPET.PNSTsin SWNcanbeplexiform,enlargeandrarelyundergomalignanttransformation. 90 Podium #50 MYXOFIBROSARCOMA:IMAGINGAPPEARANCEATPRESENTATIONANDPATTERNSOFLOCALFAILURE CoreyDaniels;BehrangAmini TheUniversityofTexasM.D.AndersonCancerCenter (Presentedby:CoreyDaniels) Objective:Toreviewtherangeofimagingfeaturesofmyxofibrosarcomaatpresentationandrecurrenceinordertofacilitateearly detectionofrecurrentdisease. Methods: This is a singleinstitution retrospective study analyzing 62 cases of myxofibrosarcoma from 2008 to 2014. Cases with imagingatrecurrencewerecomparedtotheoriginalpresentation. Results:Myxofibrosarcomaisoneofthemostcommonsarcomasinelderlypatients,withalocalfailurerateof5060%.Theimaging appearanceonMRIincludesaspectrumrangingfromawelldefinedmasstoapredominantlyinfiltratingprocess,withthemajority ofcasesfallinginthemiddle.Theimagingappearanceofrecurrentmyxofibrosarcomaresembledtheoriginaltumor:massliketumors tended to recur as nodules, while infiltrative tumors tended to recur as local soft tissue infiltration that mimicked postoperative changes. Conclusion:Theimagingappearanceofmyxofibrosarcomacanbequitevariable.Themostcommonpresentationisadominantmass withinfiltrationoftheadjacentfascialplanes;however,asmallnumberofcasescanbepurelyinfiltrative.Knowledgeofthepatterns oflocalfailureisvitalforearlydetectionofrecurrentdisease. 91 Podium #51 IMAGINGCHARACTERISTICSOFINTRAVASCULARPAPILLARYENDOTHELIALHYPERPLASIA KeithCraig;EduardoEscobar;MarkKransdorf MayoClinic (Presentedby:KeithCraig) Purpose:Intravascularpapillaryendothelialhyperplasia(IPEH)isasofttissuetumorlikebenignreactivevascularproliferationwhich maymimicanangiosarcoma.Whilemostcommonlypresentingasasuperficialmassinthehand,itmayoccurinotherlocations.We reporttheimagingfindingsofintravascularpapillaryendothelialhyperplasiain10patients. MaterialsandMethods:Weretrospectivelyreviewedourinstitutionalpathologydatabasefrom1/1/2000to1/10/2014,identifying 47patientswithIPEH,only5ofwhichhadimagingstudies.Weexpandedoursearchto1990,identifyinganadditional5patients.The diagnosisinallcaseswaspathologicallyconfirmed.ImagingreviewincludedMRIin7patientsandultrasoundin5patients(2patients hadbothultrasoundandMRIsperformed).MRimagingstudieswereevaluatedforlesionlocation,extent,size,signalintensity,signal heterogenicity and enhancement. Ultrasound studies were assessed for lesion shape, echogenicity, heterogenicity and Doppler vascularity.Demographicdatatoincludepatientage,gender,lesionlocation,andclinicalpresentationwerealsoreviewed. Results:Allpatientswithimagingstudiespresentedwitheitherpainoranenlargingmass.Intheinitialsearchofourtertiaryreferral center,only10%ofpatientshadimagingpriortosurgicalexcision.Theiragerangewas1581years(mean53years)with7females and3males.Eightof10lesionswereinthesuperficialfat.Lesionsrangedinsizefrom0.5–2.6cm(mean1.2cm).OnMRI,allof lesionsdemonstratedlowT1signalandhighT2signal(withvaryingdegreesofheterogeneity).The5patientswhounderwentcontrast enhancedstudiesalldemonstratedperipheralenhancement.Centralenhancementvaried.The5lesionswithavailableultrasound were all hypoechoic with either a round or lobulated shape. Doppler evaluation demonstrated either scattered or peripheral vascularity. Conclusion:Intravascularpapillaryendothelialhyperplasiaisnotuncommon,butinfrequentlyimaged.Itshouldbeconsideredasa diagnosiswhenoneencountersasmall,welldefined,superficial,extremitysofttissuemasswithcomplexhighsignalonfluidsensitive sequences and peripheral enhancement; the complex signal typically reflecting organizing thrombus. Knowledge of this entity is importantinthatitshistologicfeaturesmaysuggestamalignantvasculartumor. 92 Podium #52 ONSITEULTRASOUNDEVALUATIONOFHYPERACUTELOWEREXTREMITYMUSCLEINJURIESINPROFESSIONALFOOTBALL PLAYERS:PRELIMINARYEXPERIENCE RichardE.A.Walker;ShamirPatel;SarahL.Koles;SteveR.Poplawski;JamesThorne;IanJ.Auld;JamesI.Stewart;JamesR. MacKenzie UniversityofCalgary (Presentedby:RichardE.A.Walker) PURPOSE:We present ourpreliminary experience usingonsite musculoskeletal ultrasound(MSUS) for evaluation of hyperacute lower extremity muscle injuries in professional football players with correlation to both ultrasound (US) and magnetic resonance imaging(MRI)performedintheacutephaseofinjury. MATERIALS AND METHODS: Conjoint Health Research Ethics Board (CHREB) approval was obtained for this prospective study. ProfessionalfootballplayerssustainingalowerextremitymuscleinjuryandreferredforonsiteultrasoundassessmentbetweenJuly 2012andOctober2014wererecruited.Followingclinicalassessmentbythemedicalstaff,onsiteultrasoundwasperformedinthe hyperacutephase,withfollowupultrasoundandMRIperformed24dayslater,intheacutephaseofinjury.Clinicalassessmentwas performedbyasportmedicinephysicianororthopaedicsurgeonandincludedmechanismofinjury,involvedmusclegroup/muscle, siteofinjury(tendon,musculotendinousjunction(MTJ),intramuscular),andgrade(IIII).Onsiteultrasoundwasperformedusinga portableultrasounddeviceandfollowupultrasoundonageneralUSunitbyfellowshiptrainedmusculoskeletalradiologists.Follow upMRIwasperformedona1.5Twholebodyscanner.Forallmodalities,locationofinjury(musclegroupandsite),ultrasoundorMRI characteristics(size,echogenicity/signal,presenceofhaematoma),severityofmuscleinjury(gradeI,gradeII<25%,gradeII2595%, gradeIII)andmaximumcrosssectionalinvolvement(<25%,2550%,>50%)wasrecorded.Clinicalfollowupandtime(days)when athletewasclearedforfullpractice/gameparticipationwasrecorded. RESULTS:Eightplayerswereenrolled,withoneplayerwithdrawingleaving3linebackers,2defensivebacks,1widereceiverand1 runningbackforanalysis.Averageagewas27(2531).Mechanismofinjurywasaneccentriccontraction(5)andconcentriccontraction (2).Locationofinjurywashamstring(6)andadductor(1).SiteofinjurywasproximalMTJ(2),intramuscular(3),anddistalMTJ(2). Severityofinjury:GradeI(3),GradeII<25%(1),GradeII2595%(2),GradeIII(1).In4of7cases,therewasconcordancebetweenthe onsitehyperacuteUSandacutephaseUSandMRIforseverityandmaximumcrosssectioninvolvement.Notably,allwerelesssevere injuries(gradeI(3)orGradeII<25%(1)and<25%musclecrosssection).Inthreecases,thehyperacuteonsiteUSunderestimated theseverityofinjury(GradeII<25%,<25%crosssection)comparedtotheacutephasestudies(GradeII2595%(2)orGradeIII(1) and2550%(1)or>50%(2)crosssection).Onaverage,athleteswithaninjuryinvolving<25%ofmusclecrosssectionreturnedto practiceandgameparticipationsoonerthanthosewithamoreextensiveinjury. CONCLUSIONS:Ourpreliminarydatasuggeststhatonsiteultrasoundevaluationofhyperacutemuscleinjurieshasthepotentialto underestimatethegradeandextentofmoresevereinjuries.Furtherstudyisrequired. 93 94 !!!"! Focus Session/ SAMs Focus Sessions / SAMs ModuleI:ImagingofTheFoot&Ankle Sunday,March8,2015.....................................1:30p.m.–3:00p.m. SpringandLisfrancLigaments...................................................p.97 Metatarsalgia:ForefootImagingandPlantarPlateTear.......p.103 ImagingofthePostOperativeFootandAnkle......................p.113 ModuleII:CurrentSocioeconomicIssuesinMSKImaging Sunday,March8,2015.....................................1:30p.m.–3:00p.m. Radiology&MedicalMalpractice...........................................p.131 MusculoskeletalImaging:DoomedforCommoditization......p.137 AccountableCareOrganizations: HowthePracticingRadiologistCanPrepareandAdapt........p.151 ChallengesforRadiologistsinthe AgeofAccountableandAffordableCare...............................p.157 95 96 Focus Sessions / SAMs ModuleI:ImagingofTheFoot&Ankle SpringandLisfrancLigaments Presentedby:ZehavaRosenberg,MD 97 98 SPRING AND LISFRANC LIGAMENTS Focus of Talk ZEHAVA SADKA ROSENBERG Discuss the clinical, anatomy and imaging characteristics of: PROFESSOR OF RADIOLOGY AND ORTHOPEDIC SURGERY A. The spring ligament B. The lisfranc joint complex Nothing to disclose SPRING LIGAMENT SPRING LIGAMENT ● Extends from calcaneus to navicular ● Sling, supports talar head, major supporter of medial longitudinal arch ● Forms medial, plantar walls of acetabular pedis ● Acute trauma – navicular dislocation ● Degenerative: PTT dysfxn (most common), flat foot, coalition, RA, Charcot Still debatable ■ PTT dysfuction produces SL strain & flat foot OR ■ SL dysfunction causes PTT strain & flat foot ■ Cadaveric, clinical studies suggest SL, PF, other ligaments, play major supportive role to medial longitudinal arch ■ Surgical repair is being advocated Courtesy Amirsys Imaging Anatomy Courtesy Amirsys Imaging Anatomy Spring (calcaneonavicular) ligament Spring (calcaneonavicular) ligament ● Three distinct components: ■ Superiomedial ■ Mediolplantar oblique ■ Inferoplantar longitudinal Superomedial (SM) • Originates from sustentaculum tali • Inserts on superomedial navicular, tuberosity and tibiospring • Articulates w talus • Strongest, widest, most commonly torn Courtesy Amirsys Imaging Antomy Courtesy Amirsys Imaging Antomy 99 Spring (calcaneonavicular) ligament Lisfranc joint injury ● 1 in 55,000 persons per year, 0.2% 0.2 2% of 2% of all all al fractures ● Often undiagnosed, up to 20% missed mis i se ed at at initial ER visit ly ● Injury can reduce spontaneously n athletes atth hlle ette ess ● Initial x-ray can be normal esp in w 1st or 2nd degree sprain Medioplantar oblique (MPO) ● Originates at coronoid fossa, inserts to medioplantar surface of navicular, just below the tuberosity ● Striated, variable Inferoplantar longitudinal (IPL) ● Originates at coronoid fossa, inserts to navicular beak ● Strongest ● Thickest ● Rarely tears Courtesy Amirsys Imaging Antomy Lisfranc joint injury 2 Major Mechanisms ● Both low energy sprain and complete disruption carry high risk of chronic secondary disability ● Loss of longitudinal and transverse arches ● Up to 50% premature arthritis ● Require prompt recognition, anatomic reduction & stabilization ● Often season ending career in athletes ● Abduction ■ Hindfoot in fixed position, abduction of foot ■ Lateral displacement of MTs and 2nd MT fx ● Plantar flexion ■ More common Abduction injury Plantar Flexion Mechanism Symptoms ● Foot in extreme plantar-flexion “tip toe position” ● Forefoot continuous with lower extremity w longer LE lever arm ● Bending or twisting force on mid-foot ● Disruption of weak dorsal ligaments ● Depending on extent, swelling g and ecchymosis ● Damage to ligaments –Sense nse se of of instability in nssttab bililitity and pain w weight bearing y: su ssubacute, uba b cu ute te, ● Diabetic foot w neuropathy: even ev en minor min inor or painless diastasis which, w even trauma, can lead to lisfranc injury 100 Classifications Mid foot sprain classification ● Complex, many injury variations; classification systems not comprehensive ● Multiple modifications of: ■ Homolateral, divergent, isolated ■ Partial vs. complete incongruity ■ 1st MT medial displacement, w or w/o other rays ■ Lateral displacement of one or more lesser toes ■ Divergent w partial or total incongruity ● Classifications useful for radiographic description ● Not clinically useful for rx guidance or prognosis ■ Stage I – 1-2nd MT No diastasis (WB radiographs) ► Dorsal capsular tear, nl lisfranc ■ Stage II – pain, diastasis >2mm, no loss of longitudinal arch ► Dorsal, lisfranc injury, nl plantar ligaments ■ Stage III – diastasis>5mm, loss of longitudinal arch ► Dorsal, lisfranc, plantar capsular tears ■ Stage I – conservative ■ Stage II, III – surgical Nunley and vertullo 2002 Anatomy of Lisfranc ligament Conclusion ● Up to 1cm thick ● 3 components ● Plantar - ● Weight bearing or stress views ● Malalignment can be subtle w midfoot sprain ● 3 components to ligament ● Interosseous/plantar Lisfranc most important for stability ● MRI- soft tissue, marrow edema, strain or disruption of ligament ● Base of medial cuneiform to 2nd MTPlantar ● Interosseous – ● Base of medial cuneiform to 2nd MT ● Thickest, strongest ● Dorsal – ● Thinner, weaker Interosseous ● Tear of interosseous – greatest association w Dorsal instability 101 102 Focus Sessions / SAMs ModuleI:ImagingofTheFoot&Ankle Metatarsalgia:ForefootImagingandPlantarPlateTear Presentedby:HilaryUmans,MD 103 104 • _` {!| • \} ! – ! – _`{| – ~_\{ ~| – ~}^} "$' *-? " @\ ? "^ \ `}\}~" *?" ~?\ • ~"{\_}| • Spectrum of osseous stress injury • Gr I-IV, Grade IV = fracture – - " • } – { | – ~}^{ { | • ^_\} • ~\}\ $ % '$ '+-;-<-= – ^ \ Adapted from: Tibial Stress Reaction in Runners. Fredrickson M, Bergman AG, Hoffman KL, Dillingham KS J Sports Med,1995;23:472-481. • _\_} – \_}^ – • \}\' ~?\ ^ \ • Infraction elision of infarction and fracture •Subchondral collapse 2nd > 3rd MT head • Vascular compromise due to microtrauma +/or repetitive stress • Smillie Classification (I-V) • I visible only on MRI • II-III articular collapse Grade II Grade III Grade IV= Fracture • IV-V secondary DJD 105 } } • ? !'^`!' __`"`\ • $~\_^ `"_\`\ ~ ! ! ! ! ~! ~! PLANTAR Interdigital NERVES: Neuroma Anatomy PLANTAR Interdigital NERVES: Neuroma Anatomy Proper Digital Communicating Branches Proper Digital Communicating Branches Common Digital • Non-neoplastic fusiform enlargement of the plantar digital nerve Medial Plantar • Perineural fibrosis, vascular proliferation, edema of the endoneurium and axonal degeneration Lateral Plantar • At the nexus between the Common digital nerve and bifurcation of the Proper digital nerves • 3rd IS is the MOST COMMON location Medial Plantar Lateral Plantar H.Umans PLANTAR Interdigital NERVES: Neuroma Anatomy Proper Digital Communicating Branches Common Digital on-neoplastic fusiform enlargement of the plantar • • SNharp, burning pain and paresthesias • MPJnerve and IS digital Medial Plantar • May radiate to toes vascular proliferation, • Perineural fibrosis, edema of • the Tender on palpation endoneurium and axonal degeneration Lateral Plantar • • W omen more commonly affected At the nexus between the Common digital nerve and • bifurcation ? Etiology: of nerve entrapment the Proper digital/ repetitive nerves trauma • 3rd IS is the MOST COMMON location H.Umans PLANTAR Interdigital NERVES: Neuroma Anatomy Proper Digital Communicating Branches Common Digital Common Digital on-neoplastic fusiform enlargement of the plantar • • SNharp, burning pain and paresthesias • MPJnerve and IS to the tendency for the 3rd Common digital • Perhaps due Medial Plantar • May radiate to toes vascular proliferation, • Perineural fibrosis, Digital N to form from the communicating edema of • branches Tender onofpalpation the endoneurium and&axonal degeneration the Plantar Med Lat Plantar N Lateral • • W more commonly tomen the nexus between theaffected Common digital nerve and And the relative tightness of the 3rd IS • bifurcation ? Etiology: of nerve entrapment the Proper digital/ repetitive nerves trauma rd • 3 IS is the MOST COMMON location H.Umans 106 H.Umans ~} \- ~} • ? • } ~ – !! – \ ` ~_`! * – ~}} ~\__ }\ ___^\\ • ~} • ^~_\_ • $~ – \_^`"_\`\}} ` Long Axis Short Axis Short Axis T1W \- ~} • } ~ • ^` – ~}} ~\__ }\ ___^\\ • _ ^ • ! - • ~} • ^~_\_ • !"_^\ • '`\ • \^-_`- – \` \_} – "!` @' ! " • !\"\ • `\ – ! • -\_} – `^} – ^-`\ • ^ ``_! {! *| • \ • `\`"_- – ``` ` – *^ _ – *\`_^_-_`- • `\~" – _}\`-" • !}\}_ • -` \_! * • _\ - – *\ }` ^"`` @'' `}\}~" 107 \- \~! • *\ – !}" • _ }\_ • ^" • \^ • ~!}} \\ \ __ • – _} – • _-_`-{_* | • ^" • ~ Plantar Plate Tear Area 2nd IS Neuroma zone Mortons Neuroma zone – } – \_}^{| – }{}| !`_@`_' " *}\` – "\^"_}` `} – }\^\ }\ – __}} • * " __ _ • "_-` – }\`\ • !^ }^}- – ¡ \_ ` " \ • \_} }!£ • Painful symptoms + provocative tests • Do NOT reliably distinguish neuroma from PP tear • Dont believe otherwise • Anesthetic injections alleviate pain from both • Steroid injections • may relieve painful reactive inflammation • BUT can precipitate PP tear – \} • " – ~'? }\_}\`' • " – '~{ ` "| – _}\` • ~" – '¢'_}\`' \^ • – '¢ – _}\`' \ 108 ? ? • ~¢ • ~`- • _} \ • -! _ • _ ^"^_- _`- • _^" ^_-_`- • ``¤¥ $} $} • ~`- `}\`-} • \ • *}} } • }} }^} • ^\`\ }\}- • ¢\` ^_-_`- • `"_\`\ – ? \ ~ ~¢!}__ '* * • !¥`"_\`\ \`_-_`- • $}" {`| • \ {"_\`_`"| • _ '`\`"`"_\`\ • _ \`\_ -~`-! 109 ~ ? ? ~¢!}__ '* • ? • • \` – ¦ – ¦'`\} \_} • "_\" • \_}@ • !^`}__ ! • `` '^\ \ The Role of IV Gadolinium in MRI Diagnosis of MPJ Plantar Plate Tears Umans, Wilde, Morrison, Elsinger. Presented SSR, ESSR 2014 _\* \_}^ • \_}^{\ ~| • \\_ – $~`"_\`\'\_^ – ? – !? \_} __ – " _\'\_\_ – \} \\- – ! " – \§ • _\_ • ^~_\}{\ ~| • \\\^} _} – $~`"_\`\'\_^'\ – ? ' ~'_! * – }`\`\ ~" – }_` • } – $~\`\`"_\`\'\_^ – – – ? } '\ ^! * !}£ ? _\ • __ – \\\\_\_}^ • _\} – `^_\ -! -! MRI of Lesser MPJ Plantar Plate Tears and Assocd Adjacent Interspace Lesions Umans, Srinivasan, Elsinger & Wilde, Skel Rad 2014 ¢! 110 !_ ?\~}\ • `_" – – – – – – • \_ \ ? !_ \ "_ !\\ " – _^^"}{\| • ^ `" • !"_ ^\` _`_ – !"_\_ – " "}\ ~}"! _\~} ""'}`' • } • }\ → • " • ! " }\ • }\ _ • \ \ } " ^" • !"'\\ \\\}\ • *^ • _ • ~! * !¨{~!| • __ • \_}^ "{\\\| • ©?}^ • ? - • $~}\ '\^` _`"-'^`" "'}`'} @ {|'' 111 112 Focus Sessions / SAMs ModuleI:ImagingoftheFoot&Ankle ImagingofthePostOperativeFootandAnkle Presentedby:JamesLinklater,MBBS 113 114 Imaging the Post-operative Foot and Ankle Overview Lateral ligament reconstruction Syndesmosis Talar dome lesions Arthrofibrosis Neural injury Flat foot surgery Peroneal tendon surgery Plantar plate repair James Linklater Castlereagh Imaging Sydney, Australia Lateral Ankle Ligament Injury Acute Brostrom => functional rehabilitation Chronic laxity & symptomatic instability => anatomic repair (Brostrom) Video courtesy of Tom Clanton MD & Mike Coughlin MD Why Image Lateral Ligament Repairs? Pain Ê Suture 91 anchor misplacement or displacement Ê Ganglion % good or excellent Ê SPN neuroma or scar entrapment Retear 115 Suture Anchor Protrudes into PTFL Early Post op then 19 mth later SPN Stump Neuroma Ganglion Cx Brostrom Rupture ATFL repair Recurrent Instability After Brostrom Reinjury Failure Ê to address underlying deformity Cavovarus foot Functional instability despite solid ankle ligament reconstruction 116 Low Grade Interstitial Re-tear Brostrom Subacute Retear Brostrom Cavo-varus Hindfoot Anatomic Lateral Ligament Grafts Plantaris tendon Semitendinosus tendon Artificial / Polyester grafts (LARS) Non-Anatomic Lateral Ligament Reconstructions LARS Lateral Ligament Reconstruction Braided Polyester 117 Evans Modified Evans Procedure: intact Modified Evans Procedure: tear Chrisman-Snook Procedure Post Op Syndesmosis Arthroscopic assessment of syndesmotic stability Syndesmosis reduction and stabilisation MRI / CT assessment of syndesmotic alignment Complications Ê Missed syndesmosis Ê Malreduction Ê Ê Syndesmosis scar ossification & synostosis Ê Screw fracture and loosening Ê AVN distal tibia Commonest post op problem is: Ê Heterotopic painful subtalar joint due to overtightening Main role of imaging to rule out subtalar OA Arthroscopic Assessment of Syndesmosis Stability Syndesmosis Reduction and Screw Stabilisation 118 Post Syndesmosis Screw Stabilisation Syndesmosis Width on MRI Anterior margin syndesmosis 1cm above jt line Normal < 2mm Ebraheim N FAI 1997 Syndesmosis Malreduction Missed Syndesmosis “ most important independent predictor of clinical outcome” Best XR criterion: clear space < 6mm any view Naqvi NA et al, Am J Sports Med. 2012 Dec;40(12):2828-35. Acute injury Sagittal Plane Malalignment MRI Assessment Syndesmosis Healing “Many syndesmoses were malreduced on CT but went undetected by plain radiographs” Gardner M, Foot Ankle Int. 2006 Oct;27(10):788-92. 8 mths post op 119 Scar Reconstitution Syndesmosis Post Stabilisation Poorly Remodeled Scar Loss of definition of individual fascicles of AITFL AP laxity Bony Overgrowth and Degenerative Change Scar Within Syndesmotic Recess May require arthroscopic debridement Prtisch Clin Orth 1993 Synostosis Heterotopic Ossification If symptomatic may require excision Prtisch Clin Orth 1993 120 Tibial AVN Post Syndesmosis Stabilisation Screw Fracture Screw Loosening Premature Screw Removal Image courtesy of Charles Saltzman MD Tightrope Syndesmosis Stabilisation Treatment of Talar Dome Osteochondral Lesions Avoids screw Fx and stress Fx May combine one screw and tightrope 121 Debridement / chondroplasty Marrow stimulation / microfracture Osteochondral graft Autologous chondrocyte graft (MACI) Microfracture MRI Talar Dome Osteochondral Lesions Following Treatment Reparative fibrocartilage Ê Percentage fill / maturity Ê Basal and peripheral integration vs delamination Ê Surface – smooth vs irregular Ê Signal Subchondral bone Ê Bone marrow oedema change Ê Central osteophyte Ê Cystic Video courtesy of Tom Clanton MD & Mike Coughlin MD Immature Reparative Fibrocartilage Immature Reparative Fibrocartilage Crack Delaminated Reparative Fibrocartilage Mature Reparative Fibrocartilage Normal Crack Intermediate SI Reparative Fibrocartilage Mature fibrocartilage Hypointense c/w hyaline articular cartilage Basal Delamination 122 Overgrowth Subchondral Bone Central Osteophyte Cystic Change Post-debridement Talar Dome Osteochondral Graft “Mosaicplasty” MACI Pre and Post Op Quantitative Cartilage Imaging: dGEMRIC MACI T2 Map GAG content Other sequences 9 T1 9 Na rho imaging T2 mapping 9 collagen matrix Domayer et al J Magn Reson Imaging. 2010 Mar;31(3):732-9 123 Complications from Debridement of Arthrofibrosis Capsular Scar: Arthrofibrosis Complications from Debridement of Arthrofibrosis Dorsalis pedis artery false aneurysm Sural Nerve Neuroma DPN palsy Stitch In Sural Nerve Stage 2 Flat Foot Deformity 124 FDL Transfer / Calcaneal Osteotomy FDL Transfer ¾ Most popular treatment for Stage 2 PTTD FDL fixation methods ¾ ¾ ¾ PTT 3.5 times strength of FDL FDL transfer alone with flatfoot => early failure More durable reconstruction if combined with: ¾ ¾ Loop thru drill hole in navicular & side to side suture Suture anchor in medial process navicular Interweave FDL into PTT (Pulvetaft) Medial displacement calcaneal osteotomy (MDCO) Tendo Achilles lengthening (TAL) Sinus tarsi screw (arthroereisis) Debride / excise diseased segment PTT Sinus Tarsi Screw Internal Splint Medial Displacement Calcaneal Osteotomy (MDCO) Complications Ê Pain Complications very rare Ê Screw displacement Normal Sinus Tarsi Screw 92% patient satisfaction at 5 yrs Complications uncommon: Ê Worse if high BMI Ê Ongoing tendinopathy hindfoot valgus deformity Ê Progressive – Advanced stage 2 disease – FDL dehiscence – Sinus tarsi screw displacement 125 Persistent Pain Post FDL Interweave Ongoing Tib Post Tendinosis Progressive Hindfoot Valgus Dehiscent FDL Transfer and Displaced Arthroeisis Screw Displaced Sinus Tarsi Screw Kidner Procedure Excision of Type 2 accessory navicular 126 Peroneus Brevis Tendon Repair Tendinitis Post Kidner IV contrast Video courtesy of Tom Clanton MD & Mike Coughlin MD Pre-op 13 yrs post debridement & repair PB tear asymptomatic Cystic PB Tendinopathy Post-op Progressive PB tendinosis post debridement Peroneus Brevis-Longus Tenodesis Indications Ê< 50 % of peroneus brevis left after debridement or PL rupture and primary repair not feasable Ê PB 127 Post op Plantar Plate Repair and Weil Osteotomy Progressive Tendinosis Brevis to Longus Tenodesis Coughlin M. The Physician and Sports Medicine, 2011; 39(3):132-41 2yrs Post-op Plantar Plate Repair 2yrs Post-op Plantar Plate Repair Pre-op Post-op • LPP degen and tear Pre-op 8mths Post-op • Intact repair • Arthrofibrosis 128 Intact Repair: Intact Repair Dorsal subluxation – floating toe Intact Repair: Arthrofibrosis Cystic change P1 and MT head Plantar chondral wear Dorsal ganglion Reaction to Maxon Suture Synovitis -ve CRP and aspirate Case courtesy of Dr Jeff Peereboom 129 Transfer Lesion Stress # P1 4th Toe Post 2,3 Weil Overview Lateral ligament reconstruction Syndesmosis Talar dome lesions Arthrofibrosis Neural injury Flat foot surgery Peroneal tendons Plantar plate repair Transfer lesion 130 Focus Sessions / SAMs ModuleII:CurrentSocioeconomicIssuesinMSKImaging Radiology&MedicalMalpractice Presentedby:JonathanLuchs,MD 131 132 The Basics Radiology & Medical Malpractice • Radiologists have their own special set of problems. • All physicians – Average indemnification has doubled in the past 15 years. Jonathan S. Luchs, MD • Radiologists ProHEALTH Care Associates Lake Success, NY – Average indemnification has tripled in the last 15 years PIAA and ACR. Practice Standards Claim Survey 2000 Radiology Risk Malpractice Risk Management • Baker et al. RSNA 2004 • – Radiology Claims Analysis1990 – 2000 – 1 in 3 chance of being sued nationwide – Highest States(>50% have been sued) • • • • Pennsylvania • Oregon Idaho Illinois New York Michigan #1 reason a radiologist gets sued 70% of errors = perceptual^ 30% of errors = cognitive^ 2. Failure to communicate results in a timely manner – Second Highest (40 – 50 % sued) • • • • Highest areas of radiology risk:* 1. Failure to diagnose (“Missed Diagnosis”) • • New Jersey • Louisiana • Mississippi Other areas of radiology risk: 3. Self-referrals (CT screening) or Third Party referral 4. Substituted Signature – Florida (30 – 40 % sued) • Infamous for size of monetary settlements *Berlin L. et al. Am J Roentgenol 1995 ^Berlin L. et al. Am J Roentgenol 1998 Missed Diagnosis Missed Diagnosis • Most common missed diagnoses: • Mistakes (Misses) are inevitable in the practice of medicine. • Radiology literature reports a 30% error rate in radiology* – Breast cancer – Lung cancer – Spine fracture – Skewed data – Images as a part of unknowns with proven pathology – This does not refer to daily radiology practice! • If missed diagnosis of breast cancer is alleged • The more accurate number is 4% error rate^ – 41% of cases are lost* – This refers to the daily practice of radiology. *Berlin L et al. Radiology 1997 ^Siegle RL et al. Acad Radiol 1998 *PIAA and ACR. Practice standards claim survey 2000 133 Missed Lung Cancer Missed Breast Cancer • Generally accepted error rate for detection of early lung cancer • 25% of cancers can be missed on Mammography.* • 75% of breast cancers are detected at follow-up were visible in retrospect.^` • Image quality has been shown to be an issue in up to 15% of cases. • Avoid “satisfaction of search”. – 20 % to 50% • Remember to look at the places large lesion can hide.* – Mediastinum – Retrocardiac region *Berlin L. Am J Roentgenol 1999 ^Georgen SK et al. Radiology 1997 `Kerlikowshe K et al. J Natl Cancer Inst 1998 PIAA and ACR Practice Standards Claims Survey 1999 Woodring JH. Am J Roentgenol 1990 *Branstetter B et al. RSNA 2005 Reduce Missed Diagnoses Failure to Communicate • Clinical history • Communication errors are the 4th most frequent primary allegation in malpractice lawsuits against radiologists* • Causal factor in 80% of all radiology lawsuits (not primary factor)^ – Increase true positive reads^ • Look at images before reading prior report` • Maintain appropriate x-ray quality – Reduces the risk of a “miss” – Responsibility of the Radiologist *Siegle RL et al. Acad Radiol 1998 ^Berbaum KS et al. Radiology 1988 *PIAA and ACR Practice Standards Claims Survey 1997 ^Berlin L. Am J Roentgenol 2000 Self-Referrals: Failure to Communicate CT Screening Studies • “Hot Commodity” among entrepreneurial MDs • Unreasonable expectations given to the patients leads to increased litigation. • Establishment of Physician (radiologist)Patient relationship • Failure to communicate urgent or significant unexpected finding directly to the referring physician:* – Major issue in almost 60% lawsuits involving radiologists – ¾ of these were dictated in a timely fashion – Responsible to not only report the findings but also to follow up care of the patient, particularly if screening yields positive *Berlin L. Am J Roentgenol 2002 findings.* *PIAA and ACR Practice Standards Claims Survey 1997 134 Third Party Referral Substituted Signature • Danger of signing a colleagues interpretive report • Employment or Insurance company physicals • These exams may necessitate appropriate follow-up – The signer will be sued as well as the reporter. • If you sign a colleague’s report, it should be done with full understanding of responsibility and liability.* – Therefore you must: • Communicate to these results to the patient or the health care profession the patient deems care for him/her. • Document this results in the official report. *Smith JJ et al. Am J Roentgenol 2001 Positive Effect of Reducing Malpractice Risk 7 Tips to Reduce Risk* 1. Perception and interpretation can be improved with clinical information 2. Look at imaging studies before reading prior reports 3. Directly communicate when immediate treatment is needed. 4. If a signing a colleague’s report, do so with the understanding that you may be held responsible for its contents. 1. Reduce the Radiologists exposure to medical malpractice lawsuits. 2. Improve patient care 3. Improve patient safety *Raskin M. J Am Coll Radiol 2006 7 Tips to Reduce Risk* References 1) 5. Be aware of the potential obligations of self-referred or third party referred patients. 6. Communicate all significant abnormal findings in a timely manner. 7. Document all communication with date, time, who spoke and what said. 2) 3) 4) 5) 6) 7) 8) *Raskin M. J Am Coll Radiol 2006 135 Physician Insurers Association of America and American College of Radiology. Practice Standards Claim Survey. Rockville, Md: Physician Insurers Association of America; 2000. Berlin L, Berlin JW. Malpractice and radiologists in Cook County, IL: trend in 20 years of litigation. Am J Roentgenol 1995;165:781-8. Berlin L, Hendrix RW. Perceptual errors and negligence. Am J Roentgenol 1998;170:8637. Berlin L. Does the “missed” radiographic diagnosis constitute malpractice? Radiology 1997;123:523-7. Siegle RL, Baram EM, Reuter SR, Clarke EA, Lancaster JL, McMahan CA. Rates of disagreement in imaging interpretation in a group of community hospitals. Acad Radiol 1998;5:148-54. Berlin L. The missed breast cancer. Perceptions and realities. Am J Roentgenol 1999;173:1161-7. Georgen SK, Evans J, Cohen GHP, MacMillan JH. Charecteristics of breast carcinoma missed by screening radiologists. Radiology 1997;204:131-5. Kerlikowshe K, Grady D, Barclay J, et al. Variability and accuracy in mammography interpretation using the American College of Radilogy breast imaging reporting and data system. J Natl Cancer Inst 1998;90:1801-9. References 9. 10. 11. 12. 13. 14. 15. Woodring JH. Pitfalls in radiologic diagnosis of lung cancer. Am J Roentgenol 1990;154:1165-75. Branstetter B, Whetstone J, Phillips JA, et al. The most frequent diagnostic error in emergency department preliminary interpretations. In: RSNA scientific posters: Radiological Society of North America Scientific Assembly and Annual Meeting Program. Chicago, Ill: RSNA 2005:642. Berbaum KS, El-Khoury GY, Franken EA Jr, et al. Impact of clinical history on fracture detection with radiography. Radiology 1988;168:507-11. Berlin L. Malpractice issues in radiology: alliterative errors. Am J Roentgenol 2000;174:925-30. Berlin L. Communicating findings of radiologic examinations: Whither goest the radiologist’s duty? Am J Roentgenol 2002;178:809-15. Smith JJ, Berlin L. Signing a colleague’s radiology report. Am J Roentgenol 2001;176:27-30. Raskin M. Surval strategies for radiology: some practical tips on how to reduce the risk of being sued and losing. J Am Coll Radiol 2006;3:689-94. 136 Focus Sessions / SAMs ModuleII:CurrentSocioeconomicIssuesinMSKImaging MusculoskeletalImaging:DoomedforCommoditization Presentedby:PaulHarkey,MD 137 138 Disclosures Musculoskeletal Imaging: Doomed for Commoditization Nothing to disclose Paul Harkey, MD Assistant Professor of Radiology and Imaging Sciences Emory University School of Medicine Learning Objectives What is commoditization? • Understand the concept of commoditization and how it applies to musculoskeletal radiology • Merriam-Webster Dictionary Definition – “To render (a good or service) widely available and interchangeable with one provided by another company” • Recall the history of radiology and how it fits into the changing healthcare landscape • Product or service sold solely on price rather than quality or style • Discuss the importance of value-based imaging Is this the future of Radiology? How did we get here? • Radiology transformation – Rapid growth – New technologies – Centralized to distributed work flow • Fee for service rewards volume • Interpretation focused • Teleradiology expansion 139 Invisible How we are perceived • Ĺ financial pressures + Ļ reimbursement • Lack of incentive to spend large amounts of uncompensated time performing non RVU work • Once visible during hospital rounds and consultation • Increasingly unavailable and inaccessible Fee for service has emphasized radiologists as interpreters, report generators Our Current State FUTURE STATE CURRENT STATE INNOVATION RIS PACS SPEECH RECOGNITION ADV VIS,3D,CAD IMAGE DISTRIBUTION TELERADIOLOGY IMAGE SHARING STRUCTURED REPORTING COMMUNICATION TECH IMAGING CDS IMAGING EHR IMAGING PHR PRODUCTIVITY PROFITABILITY PERFORMANCE Healthcare Spending PRESENCE CURRENT PRODUCTIVITY PROFITABILITY QUALITY RELEVANCE PERFORMANCE PRESENCE Courtesy Keith Dreyer, DO FACR 2013 Health Care Reform • US Healthcare represents 17% of the GDP • Lowering costs is a primary concern for policy makers • Fee for service alternatives – ACOs and Bundled payments • Shift risk from payers to providers 140 Radiologists Worth Destiny Radiology needs to act to control our own destiny if we don’t someone else will do it for us Imaging 3.0 Medical Imaging Designed to demonstrate Radiologists’ value to patient care Delivering all the imaging care that is beneficial and necessary and none that is not Imaging 3.0 Evolution in Patient Care Imaging1.0>Imaging2.0>Imaging3.0 Imaging1.0>Imaging2.0>Imaging3.0 Imaging1.0[19201990] • ImageAcquisition Imaging2.0[1990Present] 1895 • ImprovedImageAcquisition andDigitalImageManagement • ANewKindofRay Imaging3.0[TheFuture] • IntegratingImaginginto HealthcareDelivery ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. 141 ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. Imaging1.0>Imaging2.0>Imaging3.0 Imaging1.0>Imaging2.0>Imaging3.0 Imaging1.0 Imaging2.0 [19201990] [1990Present] • ImageAcquisition • ImprovedImage AcquisitionandDigital ImageManagement ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. Imaging2.0:1990toPresent Imaging2.0:Incentives TechnologyExplosion Imaging2.0[1990– Present] Imaging technologies keepimproving Imaginggoes digitalandis storedinPACS WiththeintroductionofPACS andtheirdigitalworklists Radiology interpretation isperformed remotely radiologist productivity soars. Demandfor technology increasesto newlevels ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. 142 Imaging2.0:Downsides Imaging1.0>Imaging2.0>Imaging3.0 +$ Weenteranerawheresomelevelof inappropriateimagingoccursduetoa numberoffactors: Healthcarespending increases • Defensivemedicine • Lackofgooddecisions supporttools Imaging3.0 [TheFuture] • Difficultysharingimages • IntegratingImaginginto HealthcareDelivery • Financialincentives ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. Imaging 3.0 Relevance • Call to action to assume a leadership role in shaping America’s future health care system • Promote practice patterns that increase relevance • Develop tools and metrics • Enhance quality and demonstrate our value to the health care system • Goal to move beyond being interpreters to becoming leaders in the new and evolving health care environment Imaging3.0:TransitioningfromImaging2.0toImaging3.0 Volumebased Valuebased Transactional Consultative Radiologistcentered Patientcentered Interpretationfocused Outcomesfocused Commoditized Integral Invisible Accountable 5 Key Pillars of 3.0 • • • • • ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. 143 Imaging appropriateness Quality Safety Efficiency Satisfaction Health and Human Services Goals • • • • • • • Announced timeline for transition to value payment system • 90% Medicare payments by 2018 • HHS will increasingly rely on ACOs and other delivery models Improve patient safety Improve outcomes More cost effective Reduce waste Increase radiologists’ relevance Empower patients Anticipated Threats to Radiology Alternative Payment Models • Direct threats to revenue • Radiology groups negotiate for their components of shared savings • Payments maybe tied to performance measures • Designed to encourage cost control through economic incentives to meet certain quality performance goals • ACOs meeting quality performance standards may receive payments for shared savings – Bundled payments for episodes of care (hip fracture) – Global bundling to ACO to cover all care How Do We Get There? How Do We Get There? Cultural Shift • Evidence based medicine to guide best practices – Clinical decision support for referring physicians and radiologists • Align incentives as we move from volume to value. – Encourage rads to own all aspects of imaging – Assume a leadership role – Provide better care 144 Transparency Quality Transparency • Transparency in both quality and price • 500% market variation in price in the same area • Patients have more skin in the game and more price conscious • Patients and referrers have little insight into what high quality imaging means • Rapidly advancing price transparency and lagging quality transparency Ĺ risk of commoditization • Need to move from simple price transparency to true value transparency Value Transparency What is Value • Develop metrics and databases that demonstrate quality comparisons and highlight performance • Support professional societies in their efforts to provide quality data ܸ݈ܽ ݁ݑൌ ܳݕݐ݈݅ܽݑ ݐݏܥ Imaging 2.0 – Focus On the Interpretation Triple Aim BoardCertified Radiologists EngageinLifelong Learning Through Maintenanceof Certifications FacultyAccreditation ImagingAcquisition &Interpretation 145 Imaging 3.0 – Beyond the Interpretation Imaging Value Chain • Systematic way of examining activities and how they interact • Each link of the chain is a value opportunity • Address appropriateness, quality, safety, efficiency, satisfaction • Highlights opportunities to deliver value to patients Actionable Recommendations ForThePatientAnd ReferringPhysician ReferringPhysician ConsidersImaging BEFORE INTERPRETATION AFTER INTERPRETATION ImagingAcquisition &Interpretation ENHANCING IMAGE ACQUISITION AND INTERPRETATION PatientPhysician Report communicatio n Useful and Meaningful Imaging Appropriateness Outcome • Usable • Meaningful – Patients – System – Not just radiologists Patient Scheduling Data Mining Patient Preparation Reporting Modality operations ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. Protocol ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. 47 146 48 HealthcareDeliveryLifecycle:Scheduling Decision Support For Radiologists ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. 50 HealthcareDeliveryLifecycle:ResultsDelivery ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. 51 CaseStudy:ImageExchangeNetworkinMaine Tracking Physician Behavior – Exam Result Versus Appropriateness Score • All Good Physician Behavior – High Appropriateness Score Æ Abnormal Exam – High Appropriateness Score Æ Normal Exam – Low Appropriateness Score Æ Imaging Consult Æ Normal Exam • Poor Physician Behavior – Low appropriateness Score Æ No Imaging Consult Æ Normal Exam ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. 53 147 52 3.0 In Action MSK Ultrasound • Aligns with imaging 3.0 • Cost effective • Increases visibility – Community outreach • Helped grow our community market share Catching the Next Wave Future Responsibilities (Without Getting Stuck In The Trough And Crashing On The Reef) • Radiologists need to lead the creation of radiology performance metrics • Justify the specialty's “share” of compensation in value environment • These efforts will require a considerable investment of uncompensated time and effort Aligning Incentives PolicyMaker BuyIn Commoditization PublicPolicy Changes Clinician BuyIn • If working hours are composed solely of imaging interpretation our craft maybe commoditized • Qualitative differentiation • Changing emphasis in health care delivery and evolving reimbursement models Radiologist BuyIn Improved Patient Care Physicians Change Their Behavior Courtesy Keith Dreyer, DO FACR 2013 148 Imaging3.0Lifecycle The Future • Healthcare reform is changing how we practice • Imaging 3.0 is serving as our framework • Creating IT tools centered on this framework • Educating our profession about new paradigms • Participating with Gov and Industry to manage change ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. Summary Volume-based References Value-based Transactional Consultative Radiologist centered Patient centered Interpretation focused Outcomes focused Commoditized Integral Invisible Accountable • • • • • • • • • References • • • • • • • Abramson RG, Berger PE, Brant-Zawadzki MN. Accountable care organizations and radiology: threat or opportunity?. J Am Coll Radiol. 2012 Dec;9(12):900-6. Allen B Jr. What if all our patients were friends or family?. J Am Coll Radiol. 2014 May;11(5):435. Boland GW, Duszak R Jr, McGinty G, Allen B Jr. Delivery of appropriateness, quality, safety, efficiency and patient satisfaction. J Am Coll Radiol. 2014 Jan;11(1):7-11. Boland GW. Teleradiology for auction: the radiologist commoditized and how to prevent it. J Am Coll Radiol. 2009 Mar;6(3):137-8. Boland GW, Duszak R Jr, Kalra M. Protocol design and optimization. J Am Coll Radiol. 2014 May;11(5):440-1. Boland GW, Thrall JH, Duszak R Jr. Business intelligence, data mining, and future trends. J Am Coll Radiol. 2015 Jan;12(1):9-11. Durand DJ, Narayan AK, Rybicki FJ, Burleson J, Nagy P, et al. The health care value transparency movement and its implications for radiology. J Am Coll Radiol. 2015 Jan;12(1):51-8. Ellenbogen PH. Critical issues facing the profession of radiology. J Am Coll Radiol. 2014 Feb;11(2):103. Ellenbogen PH. Imaging 30: what is it?. J Am Coll Radiol. 2013 Apr;10(4):229. References • Imaging 3.0: An IT Framework For Radiologists’ Future, Bibb Allen, Jr., MD, FACR, RCC, Vice Chairman, ACR Board of Chancellors. Presented at the ACR Imaging Informatics Summit on October 10, 2013. Krishnaraj A, Norbash A, Allen B Jr, Ellenbogen PH, Kazerooni EA, et al. The impact of the patient protection and affordable care act on radiology: beyond reimbursement. J Am Coll Radiol. 2015 Jan;12(1):29-33. Lozano KD, Hawkins CM, Rosenthal SA, Matsumoto AH, Ma LD, et al. Driving change: taking ownership of our profession and its future. J Am Coll Radiol. 2014 Apr;11(4):359-61. Margolis NE. Imaging 30: a resident's perspective. J Am Coll Radiol. 2014 Nov;11(11):1095-7. McGinty GB, Allen B Jr, Geis JR, Wald C. IT infrastructure in the era of imaging 30. J Am Coll Radiol. 2014 Dec;11(12 Pt B):1197-204. Norbash A, Bluth E, Lee CI, Francavilla M, Donner M 3rd, et al. Radiologist manpower considerations and Imaging 30: effort planning for value-based imaging. J Am Coll Radiol. 2014 Oct;11(10):953-8. Reiner BI, Siegel EL. Decommoditizing radiology. J Am Coll Radiol. 2009 Mar;6(3):167-70. Reiner BI. Hidden costs of poor image quality: a radiologist's perspective. J Am Coll Radiol. 2014 Oct;11(10):974-8. • What is Imaging 3.0 and how is it going to be Radiology’s Escape Fire?, Dr. Geraldine McGinty, Presented at the ACR Annual Meeting and Chapter Leadership Conference (AMCLC) in May 2013. • Raising Standards, Imaging 3.0 Case Study, American College of Radiology, August 2013. • Decision Support for Ordering Appropriate High-Tech Diagnostic Imaging Scans at the Point-of-Order, whitepaper, Institute for Clinical Systems Improvement. http://bit.ly/ICSIWhitePaper • Better Together, Imaging 3.0 Case Study, American College of Radiology, August 2013. • Imaging 3.0: What Is It?, April 2013 (Vol. 10, No. 4, 229-229), Paul H. Ellenbogen. • Imaging 3.0 chapter of the ACR’s IT Reference Guide for the Practicing Radiologist, Authored by Geraldine B. McGinty, MD, MBA, FACR, Chair, ACR Commission on Economics, Bibb Allen Jr., MD, FACR. Vice Chair, ACR Board of Chancellors, Christopher Wald, MD, PhD. • Digitization of Medicine: How Radiology Can Take Advantage of the Digital Revolution, King C. Li, MD, MBA, Peter Marcovici, MD, Andrew Phelps, MD, Christopher Potter, MD, Allison Tillack, PhD, Jennifer Tomich, MD, Srini Tridandapani, PhD, MD, Academic Radiology, Vol 20, No 12, December 2013. • Keith J. Dreyer, Jonathon L. Dreyer, Imaging Informatics: Lead, Follow, or Become Irrelevant, Journal of the American College of Radiology, Volume 10, Issue 6, June 2013, Pages 394-396, ISSN 1546-1440, http://dx.doi.org/10.1016/j.jacr.2012.11.011. 149 AppendixB:Bibliography Thispresentationdrawsfrommanysourcematerialsincludingthefollowing: • Imaging3.0:AnITFrameworkForRadiologists’Future,BibbAllen,Jr.,MD,FACR,RCC,ViceChairman,ACRBoardofChancellors. PresentedattheACRImagingInformaticsSummitonOctober10,2013. • WhatisImaging3.0andhowisitgoingtobeRadiology’sEscapeFire?,Dr.GeraldineMcGinty,PresentedattheACRAnnual MeetingandChapterLeadershipConference(AMCLC)inMay2013. • RaisingStandards,Imaging3.0CaseStudy,AmericanCollegeofRadiology,August2013. • DecisionSupportforOrderingAppropriateHighTechDiagnosticImagingScansatthePointofOrder,whitepaper,Institutefor ClinicalSystemsImprovement.http://bit.ly/ICSIWhitePaper • BetterTogether,Imaging3.0CaseStudy,AmericanCollegeofRadiology,August2013. • Imaging3.0:WhatIsIt?,April2013(Vol.10,No.4,229229),PaulH.Ellenbogen. • Imaging3.0chapteroftheACR’sITReferenceGuideforthePracticingRadiologist,AuthoredbyGeraldineB.McGinty,MD, MBA,FACR,Chair,ACRCommissiononEconomics,BibbAllenJr.,MD,FACR.ViceChair,ACRBoardofChancellors,Christopher Wald,MD,PhD. • What’sPossibleinHealthCare(infographic),InstituteofMedicineoftheNationalAcademies, http://www.iom.edu/Reports/2012/BestCareatLowerCostThePathtoContinuouslyLearningHealthCarein America/Infographic.aspx • DigitizationofMedicine:HowRadiologyCanTakeAdvantageoftheDigitalRevolution,KingC.Li,MD,MBA,PeterMarcovici, MD,AndrewPhelps,MD,ChristopherPotter,MD,AllisonTillack,PhD,JenniferTomich,MD,SriniTridandapani,PhD,MD, AcademicRadiology,Vol20,No12,December2013. • KeithJ.Dreyer,JonathonL.Dreyer,ImagingInformatics:Lead,Follow,orBecomeIrrelevant,JournaloftheAmericanCollege of Radiology,Volume10,Issue6,June2013,Pages394396,ISSN15461440,http://dx.doi.org/10.1016/j.jacr.2012.11.011. • ER,Season1,Episode18,“SleeplessinChicago”.OriginalairdateofFebruary23,1995. ©2014|AMERICANCOLLEGEOFRADIOLOGY|IMAGING3.0TM |ALLRIGHTSRESERVED. 150 Focus Sessions / SAMs ModuleII:CurrentSocioeconomicIssuesinMSKImaging AccountableCareOrganizations: HowthePracticingRadiologistCanPrepareandAdapt Presentedby:JonathanFlug,MD,MBA 151 152 FinancialDisclosures AccountableCareOrganizations: HowthePracticingRadiologist CanPrepareandAdapt • None JonathanAFlug,MD/MBA AssistantProfessorofRadiology UniversityofColorado,SchoolofMedicine Outline Background • Background&Definitions • ACO’sintoday’shealthcareenvironment • RadiologywithintheACOframework • Threatsandopportunities • ToolstomanageinanACOenvironment • March2010– PatientProtectionandAffordableCareAct(PPACA) • MedicareSharedSavingsProgram– establishedAccountableCare Organizations • $10BforCMStoestablishanInnovationCentertoadministerACO’s andestablishinnovativepaymentmodels • Todate,$360Mhasbeendistributedingrants • ACRImaging3.0 • Futuredirections Definitions KeyPoint • AccountableCareOrganization(ACO) • ClinicalIntegrationProgram(CI) • PatientCenteredMedicalHome(PCMH) • Washingtonseesfeeforserviceasunsustainable • Transitionfromvolumetovalue!! 153 PioneerACO’s– Wherearetheynow? EffectofBundledPaymentsonRadiology • 32PioneerACO’sparticipatedinCMS • Atyear1: • Transitionfromprofitcentertocostcenter • Incentivetoreduceimagingutilization • • • • 13/32hadsavedenoughtoparticipateinsharedsavingsof$76M 2/32hadsharedlossestotaling$4M 9leftforthelessriskyMedicareSharedSavingsProgram 2lefttheprogramentirely • Rosman etal,JACR2014 • • • • Mostoftheemphasiswasonthesickestpatientsandprimarycare Littleemphasisonspecialtycare PredominatelyFFSforradiology Accordingtoradiologists– “NothingChanged” ACO– PaymentModels RadiologywithinanACO • Feeforservice • Riskandpaymentstructuresforindividualprovidersmayvary • Feeforservice • Onesided“sharedsavings” • Twosided“sharedsaving” • +/ Incentives • MostcommonmodelwithinACO’stodate • Capitated • Bundledpaymentsforepisodesofcare • Global(populationbased)bundling • Salariedemployment • Capitation • Bundledpaymentsforepisodesofcare • Globalbundling • Mixedmodel DirectThreatstoRadiology ACR– Imaging3.0 • Decreasedreimbursement • Perscanreimbursement • Decreasingamountofimaging • Shifttowardslowercostimaging • Financialriskforimagingperformedbynonradiologistsinacapitated model • EvaluationofovervaluedservicesbyCMS 154 FutureDirectionsandChallenges ThreatorOpportunity? • Needtoemphasizevalueovervolume • Needdatatodemonstraterealvalue • Newandunknownforall • Radiologyhasseveralinherentadvantages • ITinfrastructure • ExperiencewithQA • Experiencewithutilizationmanagementanddecisionsupport • Appropriatenesscriteria • Exposuretotheentirespectrumofpatientcare • Exposuretotheentirespectrumofphysicians References • AbramsonRG,BergerPE,BrantZawadzki MN.Accountablecareorganizationsandradiology: Threatoropportunity?JACR2012;9:900906. • AllenJRB,LevinDC,BrantZawadzki M,etal.ACRwhitepaper:Strategiesforradiologistsintheera ofhealthcarereformandaccountablecareorganizations:AreportfromtheACRfuturetrends committee.JACR2011;8:309317. • Bindman AB.Healthcarereformanditsimpactonradiologypractice.JACR2014;11:252254. • ButtsD,Strilsky M,Fadel M.The7componentsofaclinicalintegrationnetwork. http://www.beckershospitalreview.com/hospitalphysicianrelationships/the7componentsofa clinicalintegrationnetwork.html.AccessedDecember10,2014. • HarveyHB,GowdaV,GazelleS,etal.Theephemeralaccountablecareorganization– an unintendedconsequenceoftheMedicaresharedsavingsprogram.JACR2014;11:121124. • Mukherji SK.Thepotentialimpactofaccountablecareorganizationswithrespecttocostand qualitywithspecialattentiontoimaging.JACR2014;11:391396. • PhamHH,CohenM,ConwayPH.Thepioneeraccountablecareorganizationmodel:improving qualityandloweringcosts.JAMA2014;312(16):16351636. • Rosman DA,Farinhas J,Kassing P,etal.Radiologyinpioneeraccountablecareorganizations:Much adoaboutnothing?JACR2014Inpress.Accessedonline,http://www.jacr.org/article/S1546 1440%2814%29001513/abstract. • SeltzerSE,LeeTH.ThetransformationofdiagnosticradiologyintheACOera.JAMA 2014;312(3):227228. 155 156 Focus Sessions / SAMs ModuleII:CurrentSocioeconomicIssuesinMSKImaging ChallengesforRadiologistsinthe AgeofAccountableandAffordableCare Presentedby:S.Yadavalli,MD,PhD 157 158 Goals and Objectives Challenges for Radiologists in the Age of Accountable and Affordable Care • Understand some of the current changes in health care delivery and how these impact radiology in terms of workflow and reimbursement. • Quality of care, accountability, safety and cost cutting are some of the most important factors driving changes in health care. Imaging is a significant part of health care and perceived as expensive with great potential for cost cutting and savings. Radiologists need to find opportunities to be in the forefront of change in this environment so that they do not suffer further losses in revenue and are able to negotiate better reimbursement where incentives are based on quality and accountability. • Recognize the importance of participating and assuming leadership roles in strategic planning and adoption of technology by the organizations and health care communities in which radiologists work. • Radiologists could use their position as an important link between primary care and specialty care physicians in the context of Accountable Care Organizations to gain a seat at the table or a leadership role in the endeavor to meet quality performance standards. • Radiologists can use their knowledge in the areas of information technology, safety and oversight of imaging equipment to improve efficiency, quality and better coding to decrease revenue loss. • Recognize that for survival and success in this new age we have to shed our mantle of apathy, emerge from our dark caves, learn to network, gain a position of strength in the social and political map of our work environment, and train the next generation of radiologists to assume leadership roles. S Yadavalli, MD PhD Department of Diagnostic Radiology Beaumont Health System and Oakland University William Beaumont School of Medicine ICD In the News ICD-Codes: Fine Granularity ICD -International Classification of Diseases ICD Coding • First developed in France in 1893 and adopted in USA in 1898 • Codes written by World Health Organization but tailored by each country • Centers for Medicare and Medicaid Services (CMS) - National Center for Health Services Up-to-date classifications in ICD-10 will provide much better data • • ICD-10 release by WHO in 1994 • USA ICD-10 – Quality measures – medical processes and outcomes • Safety and efficacy of care • Accurate reimbursement • Design systems for processing claims and payments • Epidemiological studies and clinical trials – Clinical Modification Codes • Medical diagnosis • Patient symptoms Procedure Coding System (USA only) • – Procedures in the inpatient setting 141000 codes Setting healthcare policy • • Design of healthcare delivery systems • 1-3 = category • Resource allocation and utilization • Improve clinical, financial, and administrative performance • 4-6 = etiology, anatomic site, severity, and other clinical details • 7 = Extension • • Prevention and detection of healthcare fraud and abuse • Tracking public health and risk – Morbidity and Mortality Statistics 159 Code with 3-7 characters • ICD-9 – 17000 codes • Lacks specificity • Code has 3-5 characters • USA only one using it Accountable Care Organizations Why do I have to know anything about the ICD codes? • Required by Patient Protection and Affordable Care Act – All HIPAA covered entities • Non compliance • • Network of doctors and hospitals – Provide coordinated care to patients – Share financial and medical responsibility – Each patient’s care must be coordinated by a primary care physician Patient Protection and Affordable Care Act (PPACA) – – Government sanctions – Inability to bill Medicaid and Medicare and some third party payers • Ordering Physicians ÎScheduling Î RegistrationÎgÎTechnologistsÎgÎRadiologist ÎgÎBillersÎÎÎÎÎgg • Radiologist Report needs to include detailed information • – laterality, – Anatomic detail – exact site of fracture, quadrant of the organ etc. – – – open v. closed Timeline: acute v. chronic, initial encounter vs follow up Sequela Medicare Shared Savings Program – Sets the basic requirements for ACOs – ACOs meeting quality performance standards – receive benefits for shared savings • Fee for service (unlike managed care) • Goal is to limit unnecessary spending • Incentive for efficiency – reward when providers keep costs down • Require doctors and hospitals to meet specific quality benchmarks • Focus = Prevention and Quality of management of patients with chronic diseases • Providers benefit by keeping their patients healthy and out of the hospital Documentation will determine final code for billing Potential Effects of ACOs on Radiology • • • • • Meaningful Use Decrease in per exam reimbursement Decrease in utilization of radiology services Use less expensive imaging exams Imaging by other providers Integration of health systems for cost cutting • Legislation first introduced in American Recovery and Reinvestment Act of 2009 • Multistage incentivized program to adopt certified electronic health record technology (CEHRT) • Measures in the program did not seem relevant to radiologist’s daily workflow – Decreased negotiating power for Radiologists • Malpractice risk for Radiologists if exams declined under cost cutting pressures • ACR addressing concerns with CMS and National Coordinator for Health IT (ONC) • For now radiologists can claim exemption from MU requirements • RIS and PACS need to be MU certified • Future penalties Burning platform • Opportunities for Radiologists • Cuts in reimbursement • multiple procedure payment reduction (MPPR) • Deficit Reduction Act –reimbursement cap • Utilization rate changes • PPACA Move to the table from the dark rooms • Leadership roles in the health care organization – become part of the social and political environment of the hospital and community • Assume leadership role in providing cost cutting solutions while maintaining quality • Most knowledgeable about the technical and operational issues related to expensive radiology equipment • Expertise in information technology (IT) and large scale data management • Link between primary care and specialty care physicians • Bundling of codes for combined procedures • MPPRs on technical and professional payments Burning platform, culture shift (from apathy), image problem • • Medical device tax • Leaders – radiology, business, economics and practice management 160 • Use of ACR appropriateness criteria • Decision support systems to improve quality and decrease utilization • Use these as leverage for better incentives and reimbursement Opportunities for Radiologists • Opportunities • Highlight Quality and Safety Programs run by Radiologists – Negotiate Incentives – patient centered • Not volume based Radiation safety – Oversight of equipment – Contrast administration policies – Maintenance of facility accreditation – Education of ancillary staff and technologists • As experts in all aspects of imaging we can optimize the imaging experience of the patient in the emergency room and inpatient settings to decrease length of stay • Market these services to administration and to patients • Communication • Negotiate with ACOs to prohibit self referral by non radiologisits • payment for value based service – improve quality • Decreased reimbursement per exam – increase productivity to keep income • Improve efficiency • Limit on how much productivity can be increased • Leadership training • Knowledge (outside of radiology), persuasive, influential and effective • Involvement at local and national levels Business Intelligence • Business Intelligence Making data work for you • Radiology – Data extraction and Transformation – Workflow efficiency – turn around time – Process analysis and improvement – Outcome measures – Throughput – identify inefficiencies in how patients navigate through radiology – Performance assessment – graphical dash boarding – Alerting – Workflow analysis – Scenario modeling • Wait time for each stage, registration, changing time etc – Safety – radiation dose, complication rates of biopsies and interventions – Outcomes – No shows – Patient satisfaction – Mismatch between coding and study reporting – decrease revenue loss • Analysis of data – • Radiology Information System (RIS) Descriptive (what has happened) – Predictive (what could happen – use data to model and simulate future) – Prescriptive (what should happen – optimize for best outcomes) – Advanced reporting capabilities – improve efficiency • Electronic Medical Records (EMR) • Radiology Information System (RIS) • Integrate data RIS and EMR • Decision support to referring physicians – Advanced reporting capabilities – improve efficiency Coordinating Patient Care Coordinating Patient Care • RIS • • -scheduling, resource management, exam performance tracking, interpretation, result distribution, billing Management of unread cases in worklists with priority cases highlighted – Improve turnaround time for emergency and inpatients • EMR • Priority result notification system integrated with PACS • Integration – seamless information sharing • Protocol scheduled exams tailored to clinical history – Work flow in radiology initiated in office by order placement in EMR • Routine protocols available to technologists – Ends with report and images being made available in EMR • EMR/RIS – contrast allergies • Decision support tools may replace need for preauthorization in some cases • Documentation – contrast administered • Patient demographics and insurance information for billing – radiation dose for exam • Scheduling of procedures and management of open appointments – Medication reconciliation • Seamless integration between RIS and PACS • Flow of information images to PACS and into modality specific worklist 161 What else can we do? • Summary Contribute to ACR and Radiology advocacy groups • • Accreditation • Practice building activities by all in a group • Develop and maintain relationships • Service first mentality SAM Question 1 References ICD Codes in United States are overseen by • Abramson RG et al. Accountable Care Organization and Radiology: Threat or Opportunity? JACR 2012;9:900-906. Sherry CS and Canon CL. An Introduction to “Business Essentials”. JACR 2014;11:110111. McEnery KW. Coordinating patient care within radiology and across the enterprise. JACR 2014;11:1217-1225 Muroff LR. Culture shift: An imperative for future survival. JACR 2013;10:93-98. Medverd JR et al. ACR white paper: new practice models-hospital employment of Radiologists : A report from the ACR future trends Committee. JACR 2012;9:782-787. Ellenbogen PH. ICD 9-10-11 Whoa! JACR 2013;10:885. ICD-10 Overview_presentation, CMS http://www.cms.hhs.gov/ICD10 ICD-10 Transition: An Introduction eHealth University presentation CMS Durand DJ and Kohli MD. Advanced practice quality improvement project: how to influence physician radiologic imaging ordering behavior. JACR 2014;11:1155-1159. Krishnaraj A et al. Meaningful use: participating in the federal incentive program. JACR 2014;11:1205-1211. Levin DC et al. Ensuring the future of radiology: How to respond to the threats. JACR 2013;10:647-651. Cook TS and Nagy P. Business Intelligence for the radiologist: making your data work for you. JACR 2014;11:1238-1240. • • • • • • • • • • • A. World Health Organization B. National Center for Health Services C. Centers for Disease Control and Prevention D. National Institutes of Health Ref: SAM Question 2 SAM Question 3 Who needs to transition to ICD 10? Accountable Care Organizations A. Only those who submit Medicare and Medicaid claims for Patient B. Only hospitals and practices involved in data collection epidemiology A. New form of insurance providers created under the Protection and Affordable Care Act B. Are required to have a primary care physician coordinate care of every patient in the network C. All covered by the Health Insurance Portability and Accountability Act (HIPAA) C. Do not allow fee for service payment D. Only institutions that have inpatient and outpatient facilities Ref: Ellenbogen PH. ICD 9-10-11 Whoa! JACR 2013;10:885. ICD-10 Overview_presentation, CMS http://www.cms.hhs.gov/ICD10 ICD-10 Transition: An Introduction eHealth University presentation CMS D. Networks made of physicians only Ellenbogen PH. ICD 9-10-11 Whoa! JACR 2013;10:885. ICD-10 Overview_presentation, CMS http://www.cms.hhs.gov/ICD10 ICD-10 Transition: An Introduction eHealth University presentation, CMS Ref: Threat or 162 Abramson RG et al. Accountable Care Organization and Radiology: Opportunity? JACR 2012;9:900-906. SAM Question 4 Business Intelligence (BI) – Which one is incorrect? the A. Allows for analysis and optimization for best outcomes using current data and models and simulations based on data B. Is a commercially available computer software certified by CMS that can do automated billing after ICD 10 is implemented C. BI tools are useful to look for mismatches in Radiology reports and coding to decrease loss of revenue D. BI tools can be used to extract, track and report radiation dose indices Ref: Cook TS and Nagy P. Business Intelligence for the radiologist: making your data work for you. JACR 2014;11:1238-1240. 163 164 e#!! ePosters ePoster* Complete Listing *Asthesesessionsarenotmoderated,ePostersarenotCMEaccredited Location:ArizonaBallroom Sunday,March8,2015.....................................7:00a.m.–4:30p.m. Monday,March9,2015....................................7:00a.m.–12:30p.m. Tuesday,March10,2015..................................7:00a.m.–12:30p.m. Wednesday,March11,2015............................7:00a.m.–10:30a.m. ePoster* Complete Listing *Asthesesessionsarenotmoderated,ePostersarenotCMEaccredited Interventional ePoster#1 ANEWMSKAPPLICATIONOFMICROWAVEABLATION PritiPatil;KennethLee UniversityofWisconsin ePoster#2 SUBCHONDROPLASTY:ANEWMINIMALLYINVASIVEPROCEDUREFORTREATMENTOFKNEE PAINASSOCIATEDWITHARTHRITIS AlisinaShahi;WilliamMorrison;AdamZoga;JohannesRoedl;PeterWahba ThomasJeffersonUniversity ePoster#3 ARTHROCENTESIS:AMULTIMODALITYAPPROACH CorrieM.Yablon;NathanielBMeyer;JimSWu;YoavMorag; SungMoonKim;DavidPFessell;JonAJacobson UniversityofMichigan ePoster#4 ULTRASOUNDGUIDEDANTERIORSCALENEMUSCLEINTERVENTIONSFORDIAGNOSTIC EVALUATIONANDTREATMENTOFTHORACICOUTLETSYNDROME MichaelG.Rodriguez;MasonB.Frazier;BenjaminTriche;TatumA.McArthur,PhikipChapman, MD UniversityofAlabamaatBirmingham ePoster#5 CTGUIDEDLUMBARFACETSYNOVIALCYSTINTERVENTION:WHATTHERADIOLOGISTNEEDS TOKNOW TatumA.McArthur;JessicaL.Millsap;NicholasG.Clayton;ZacharyLambertsen;CarlA.Narducci UniversityofAlabamaatBirmingham ePoster#6 ASSESSMENT OF TENDON AND TENDON SHEATH PATHOLOGY FOLLOWING THERAPEUTIC INJECTION:THETENOSONOGRAPHICEFFECT JenniferLMcOsker;RonaldSAdler;GinaCiavarra;RenataLaRoccaVieira;JamesBabb NewYorkUniversityLagoneMedicalCenter LowerExtremity/Other ePoster#7 NORMALSKELETALDEVELOPMENTANDIMAGINGPITFALLSOFTHECALCANEALAPOPHYSIS: MRIFEATURES Ignacio Martin Rossi; Zehava Sadka Rosenberg; Chimere MbaJonas; Jonathan Zember; ChristopherMorley;AnneWang NewYorkUniversityLagoneMedicalCenter ePoster#8 THEHIDDENSECRETSOFTHEAPRADIOGRAPHOFTHEANKLE IgnacioMartinRossi;ZehavaSadkaRosenberg;JonathanZember NewYorkUniversityLagoneMedicalCenter ePoster#9 CHARCOTFOOT:THESPECTRUMOFFINDINGS,WITHANEMPHASISONSOFTTISSUECHANGES SayedAli;ParthaHota TempleUniversity ePoster#10 POSTEROMEDIALEXTRAARTICULARCOALITION:POORLYRECOGNIZEDANDUNDER DIAGNOSEDENTITYINTHEHINDFOOT CatherinePetchprapa;ZehavaRosenberg NewYorkUniversityLagoneMedicalCenter 166 ePoster* Complete Listing *Asthesesessionsarenotmoderated,ePostersarenotCMEaccredited ePoster#11 FOOTARTHRODESISHARDWARE:AREVIEW Tatum A. 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Jordan Gross; Michelle McNee; Benjamin Levine; Benjamin Plotkin; Kambiz Motamedi; Leanne Seeger UCLAHealthSystem ePoster#25 PEARLSANDPITFALLSOFNAFPETMRIINTHEEVALUATIONOFPROSTATECANCERPATIENTS FOROSSEOUSMETASTATICDISEASE TaylorJ.Stone;LuisS.Beltran NewYorkUniversityLagoneMedicalCenter ePoster#26 NOTHINGGOODHAPPENSINTHEFIBULA:IMAGINGDIFFERENTIALOFFIBULARTUMORS ScottSchiffman;ValeriyKheyfits;GregoryDieudonne;JohnnyMonu;XiWang UniversityofRochester ePoster#27 WORKSTATIONBASEDCTRECONSTRUCTIONFORTHEDETECTIONOFVERTEBRALBODY COMPRESSIONFRACTURES:WHATAREWEMISSING? KevinPreston;JosephBestic;HilliaryGarner;JeffreyPeterson;DanielWessell MayoClinicJacksonville ePoster#28 MRICHARACTERISTICSOFINTRANEURALSYNOVIALSARCOMA UsamaSalem;BehrangAmini;JeanneM.Meis MDAndersonCancerCenter UpperExtremityI ePoster#29 REVERSETOTALSHOULDERARTHROPLASTY:RADIOLOGICIMAGINGANDEVALUATION SailajaYadavalli;ErgentZhiva;SunitVekaria BeaumontHealthSystem ePoster#30 IMAGINGSPECTRUMOFPECTORALISTEARS:PREOPERATIVEANDPOSTOPERATIVEMRI FINDINGS ShefaliKothary;GabrielleKonin;DarrylSneag;FrankCordasco HospitalforSpecialSurgery ePoster#31 DIAGNOSTICACCURACYOFSHOULDERMRIINCHARACTERIZINGBICEPSTENDONPATHOLOGY UTILIZING STANDARD IMAGING PLANES VERSUS A DOUBLE OBLIQUE T2 WEIGHTED FAT SUPPRESSEDSEQUENCE ScottSheehan;HumbertoRosas;JasonStephenson UniversityofWisconsin 168 ePoster* Complete Listing *Asthesesessionsarenotmoderated,ePostersarenotCMEaccredited ePoster#32 INFERIORSUBSCAPULARISMUSCLESTRAIN–ANUNUSUALFINDINGINOVERHEADTHROWING ATHLETESWITHPOSTERIORSHOULDERPAIN EricMTarkowski,KevinJBlount,StephenMGryzlo,ImranMOmar NorthwesternUniversityFeinbergSchoolofMedicine Hip ePoster#33 MRIMAGINGOFATHLETICPUBALGIA:NORMALANATOMY,COMMONFINDINGSAND PITFALLS AbhijitDatir;BinduAvutu;TarekNHanna;DouglasDRobertson EmoryUniversity ePoster#34 COMPLICATIONSOFHIPARTHROSCOPY JuliaCrim UniversityofMissouri ePoster#35 MRIOFPROXIMALFEMURMICROSTRUCTUREASNOVELBIOMARKERSOFSKELETALFRAGILITY ANDFRACTURERISK KevinChu;RonaldAdler;GregoryChang NewYorkUniversityLagoneMedicalCenter ePoster#36 TRAUMATICSACRALFRACTURES:THREEIMPORTANTFRACTURECATEGORIES PushpenderGupta;ScottWuertzer;LeonLenchik WakeForrestSchoolofMedicine ePoster#37 3DMRVS.3DCTOSSEOUSRECONSTRUCTIONSOFTHEHIPUSINGAGRADIENTECHOBASED2 POINTDIXONRECONSTRUCTION:ACOMPARISONSTUDY Avner Yemin; Luis S. Beltran; Jonathan Vigdorchik; Michael Bloom; James Babb; Soterios Gyftopoulos NewYorkUniversityLagoneMedicalCenter UpperExtremityII ePoster#38 CONCEPTSOFOPERATIVETREATMENTINSCAPHOLUNATEINSTABILITY:ANIMAGING PERSPECTIVE KimiaKKani;HyojeongMulcahy;FelixS.Chew UniversityofWashington,Seattle ePoster#39 MRIMAGINGOFSOFTTISSUEINJURIESOFTHEFINGERS KimiaKKani;HyojeongMulcahy;FelixS.Chew UniversityofWashington,Seattle ePoster#40 COSTOCHONDRALINJURIES:HOWNOTTOMISSIT! ManickamKumaravel;NicholasBeckmann;SusannaSpence;UsmanAnwer UniversityofTexas,Houston 169 ePoster* Complete Listing *Asthesesessionsarenotmoderated,ePostersarenotCMEaccredited TumorII/Misc ePoster#41 SONOGRAPHYOFORTHOPEDICHARDWARECOMPLICATIONS JonellePetscavageThomas;CristyGustas PennState ePoster#42 DEBUNKINGTHEMYTHSOFGOUT SayedAli;StephenLing;IreneTan;AnneMarieSchorpion Temple ePoster#43 NANOFRACTURES:ALLYOUWANTEDTOKNOW! ManickamKumaravel;NicholasBeckmann;SusannaSpence UniversityofTexas,Houston ePoster#44 SECRETSOFTHEPERIOSTEUM:CLUESTOUNDERLYINGOSSEOUSANDMETABOLICDISEASES ChuanxingQu;VincentLeeMD,AndrewCordle;CynthiaABritton UniversityofPittsburghMedicalCenter ePoster#45 PITFALLSINCERVICALSPINECTINTHETRAUMAPATIENT JoesphLivingston;JohnBoardman;AndrewWilmot;CarolL.Andrews UniversityofPittsburghMedicalCenter ePoster#46 BACKPAININCHILDRENANDYOUNGADULTS:BEYONDSPONDYLOLYSIS ShefaliKothary;DarrylSneag;DouglasMintz;YoshimiEndo HospitalofSpecialSurgery ePoster#47 FACINGTHEFACTS:USINGPATTERNRECOGNITIONTOMAKEFACIALCTEASY SusannaC.Spence UniversityofTexas,Houston ePoster#48 MAGNETIC RESONANCE IMAGING FINDINGS OF PERIPHERAL NERVES IN CHARCOTMARIE TOOTH SangeetaChaudhary;JonellePetscavageThomas;StephanieABernard;EricAWalker HersheyMedicalCenter ePoster#49 SCHWANNOMATOSIS:REVIEWOFIMAGINGANDCLINICALFEATURESINARECENTLY RECOGNIZEDENTITY ShivaniAhlawat;AsadBaig;JaishriBlakeley;MichaelA.Jacobs;LauraMFayad JohnsHopkinsUniversity ePoster#50 TRAUMATICNEUROMAS:COMMONMRIFEATURES ShivaniAhlawat;AllanJBelzberg;ElizabethMontgomery;LauraMFayad JohnsHopkinsUniversity 170 ePoster #1 ANEWMSKAPPLICATIONOFMICROWAVEABLATION PritiPatil;KenLee UniversityofWisconsin (Presentedby:PritiPatil) Microwaveablation(MWA)isthedirectapplicationofthermaltherapytoinduceinsitudestructionoftissuesviacoagulationnecrosis. MWAisanemergingtechnologytypicallyusedforcancertherapiesthatissupplantingradiofrequencyablation(RFA)foritseaseof use and more efficacious destruction of tumor tissue. The goal of this educational exhibit is to review MWA, to show its current indications,andtointroduceanewMSKpainmanagementapplicationforMWA. MWAuseselectromagneticwavestocausecellulardeathviacoagulationnecrosis.TherearedifferentapproachestoMWA,including percutaneous, laparoscopic, and open surgical. MWA has historically been used for treatment of liver tumors, lung tumors, renal/adrenaltumors,andosseousmalignancies. However, a new application of MWA is for the treatment of neuropathicrelated pain. Inguinal neuralgia is a welldocumented complicationfollowingsurgicalproceduresthatrequirelowabdominalincisionsandmeshrepair.Itisachallengingconditiontotreat, withinconsistentresponsestoconservativemeasuresandsurgicalmanagement.Arecentstudyhasshownpromisingresultsforthe treatmentofinguinalneuralgiausingCTguidedRFA. To evaluate the utility of MWA as a viable alternative minimally invasive treatment for chronic inguinal neuralgia, 7 USguided microwave nerve ablation procedures were performed. Each patient underwent a selective diagnostic USguided steroid and anestheticnerveblock1monthpriortoablationdemonstratingnotonlytemporaryreliefoftheirtypicalsymptomsbutnoadverse effects. One of three nerves known to cause iliodynia were ablated after a positive steroid/anesthetic response – ilioinguinal, iliohypogastric,orgenitofemoralnerve.Painresponsewasmeasuredonavisualanalogscale(VAS)from0to10beforeablationand at2weeks,1,6,and12monthfollowingablation.100%instantpainreductionwasobservedin85.7%ofproceduresatthe1month followupandmaintainedin71.4%ofproceduresatthe6and12monthfollowup.Therewerenoadversecomplications. Conclusion:MWAisanemergingtoolthatmayhaveusefulMSKpainmanagementapplications,includingthetreatmentforchronic inguinalneuralgia. 171 ePoster #2 SUBCHONDROPLASTY:ANEWMINIMALLYINVASIVEPROCEDUREFORTREATMENTOFKNEEPAINASSOCIATEDWITHARTHRITIS AlisinaShahi;WilliamMorrison;AdamZoga;JohannesRoedl;PeterWahba ThomasJeffersonUniversityHospital (Presentedby:AlisinaShahi) Degenerativejointdisease(DJD)isoneoftheleadingcausesofmorbidityintheUnitedStates.Billionsofdollarshavebeendirected towarddevelopmentofcartilagereplacementandrepairtechniques,witharguablylimitedsuccess.Thismaybebecausepainreliefis amajorfactordeterminingafavorableoutcome.Sincehyalinecartilageisnotinnervated,painmaynotbealleviatedbyrepairingor replacingcartilagealone.Previousworkhassuggestedthatpainfromarthritisisprimarilyrelatedtosynovitisandsubchondralbone marrow lesions (BMLs) associated with chondrosis. BMLs are a heterogeneous group of conditions and histology ranging from subchondralfracturetoreactiveedema,cysticchange,necrosisandarticularsurfacecollapse. Thesubchondroplastyprocedurehasbeendevelopedtotreatpatientswithosteoarthritisoftheknee,notbytreatingthecartilage lesionitself,butinsteadbyaddressingtheBMLthatmaybecontributingtopain.Subchondroplastyismuchlikevertebroplasty;the principle is to inject material into the subchondral bone, specifically within a region of bone marrow edema identified as being associated with painful arthritis or chondrosis. The material injected is a calciummagnesiumphosphate bone substitute. Theoretically,thematerialinitiallysupportsthearticularsurfaceandfillsareasoftrabecularmicrofracture;eventuallythecalciumsalt isresorbedandbecomesreplacedwithreparativebone. Subchondroplastycanbeanoptionforapopulationofpatientswhoarebetweenthestagesofafocalcartilagelesionandsevere arthritis.Itmaybeparticularlyusefulfortreatmentofsubchondralinsufficiencyfractures(formerlyknownasSONK).Itcanpotentially delayorevenobviatejointreplacement.Radiologistsshouldbeawareofthisprocedureanditscharacteristicimagingappearance. Thisposterwilldemonstratethesubchondroplastytechnique,imagingfindingsbeforeandaftertheprocedureandcaseswithclinical followup. 172 ePoster #3 ARTHROCENTESIS:AMULTIMODALITYAPPROACH CorrieM.Yablon UniversityofMichigan (Presentedby:CorrieM.Yablon,MD) Background Information: Image guided arthrocentesis procedures are extremely common in the daily work of both the musculoskeletalandgeneralradiologist.Therearemanyindicationsfortheseproceduresincluding:diagnosticaspiration;therapeutic injection; and MR or CT arthrography. Thus, it is imperative that the training or practicing radiologist acquire the technical skills requiredtoperformsuchprocedures.Moreover,theclinicianshouldbefamiliarwithmultipleapproachesandimagingmodalitiesfor eachjointinordertotailorpatientcaretoeachclinicalscenario. EducationalGoals/TeachingPoints:1.Thiseducationalexhibitwillprovideanoverviewoftheindicationsandtechniquesforseveral approachestocommonlargeandsmalljoints,aswellasuncommonsmalljointsencounteredinclinicalpractice.2.Indications,contra indications,andcomplicationswillbediscussed.3.Commonpearlsandpitfallswillbereviewedforeachjoint. Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: Although most joint related procedures are performed with fluoroscopicguidance,therearemanycaseswhereultrasoundorCTguidanceisuseful.Ultrasounddoesnotuseionizingradiation and provides additional benefits including direct visualization of neurovascular structures, soft tissue anatomy and potential pathology,aswellasdocumentationoftheneedleatthetarget.Adetailedunderstandingofeachjoint’sanatomyisrequiredinorder toproperlyidentifylandmarks,recognizecommonpitfalls,andavoidcomplications.Inthehip,directanterior,anteriorobliqueor lateraltrochantericapproachescanbeutilized.Intheshoulder,anteriorapproachesusingtheSchneidertechniqueorrotatorinterval approach,aswellsastheposteriorapproachwillbereviewed.Alateralormedialpatellofemoralapproachcanbeusedintheknee. Lateral or posterior approaches are useful in the elbow. US and CT guided sacroiliac joint injections will be reviewed. Multiple compartmentwristarthrographywillbedemonstrated.Inaddition,fluoroscopic,USandCTguidancewillbediscussedwithrespect tothemoreuncommonjoints,includingsmalljointsofthehandsandfeet.InplaneandoutofplaneinjectiontechniquesusingUS guidancewillbedemonstrated. Conclusion: It is essential that the practicing radiologist possess the technical skills required to perform common joint related procedures.Theradiologistshoulddevelopadetailedunderstandingofanatomy,commonpitfalls,andmultipleapproachestoeach jointinordertotailoreachexaminationtothepatient’sneeds.Whilefluoroscopyremainsthemostutilizedmodality,ultrasoundand CTprovideanumberofusefulbenefitsforcliniciansandtheirpatients. 173 ePoster #4 ULTRASOUNDGUIDEDANTERIORSCALENEMUSCLEINTERVENTIONSFORDIAGNOSTICEVALUATIONANDTREATMENTOF THORACICOUTLETSYNDROME MichaelG.Rodriguez;MasonB.Frazier;BenjaminTriche;TatumA.McArtur TheUniversityofAlabamaatBirmingham(UAB) (Presentedby:MichaelG.Rodriguez,MD) Introduction:Thethoracicoutletincludesmultipleneurovascularstructuresthatcanbecomecompressedastheycrossthethree majorcompartmentsandcanleadtothoracicoutletsyndrome.Imagingplaysanimportantroleinthediagnosticevaluationofthis pathologicentity.Imageguidedinterventionscanplayaroleinthediagnosticworkupofthoracicoutletsyndromeinordertobetter evaluatepatientsthatwillhaveabetteroutcomefollowingsurgicaldecompression.ImageguidedbotulinumtoxinAinjectioncan alsoplayaroleinthetreatmentofthoracicoutletsyndrome. TeachingPoints:1.Toreviewtheanatomyofthethoracicoutlet.2.Toreviewtheclinicalpresentationandimagingappearanceof thoracicoutletsyndrome.3.Todiscussthetechniquesinperformingultrasoundguidedinterventionsforthediagnosticevaluation and treatment of thoracic outlet syndrome. 4. To review the complications associated with ultrasoundguided interventions for thoracicoutletsyndrome. Table of Contents/Outline: 1. Anatomy of the thoracic outlet. 2. Clinical presentation of thoracic outlet syndrome 3. Imaging appearanceofthoracicoutletsyndromeonradiographs,CT,MR,andultrasound.4.Imageguidedinterventionsa.Ultrasoundguided anterior scalene block. b. Ultrasoundguided anterior scalene botulinum toxin A injection. 5. Complications a. Injury to adjacent vascularstructures.b.Transientparalysisofthebrachialplexus,sympatheticchain,andvagusnerve. Conclusion:Knowledgeofthestructureswithinthethoracicoutletiscriticalinthediagnosticevaluationofthoracicoutletsyndrome. Recognition of this disorder can help in treatment planning, both surgical and nonsurgical. Imageguided intervention serves an importantrolefornotonlytheinitialdiagnosisbutalsoforthetreatmentofthoracicoutletsyndrome. 174 ePoster #5 CTGUIDEDLUMBARFACETSYNOVIALCYSTINTERVENTION:WHATTHERADIOLOGISTNEEDSTOKNOW TatumA.McArthur;JessicaL.Millsap;NicholasG.Clayton;ZacharyLambertsen;CarlA.Narducci TheUniversityofAlabamaatBirmingham(UAB) (Presentedby:TatumA.McArthur,MD) Introduction:Lumbarfacetsynovialcysts(LFSC)thatprojectintothespinalcanalcancauselowbackpain,radiculopathy,neurogenic claudication,motorweakness,andsensoryloss.Treatmentoptionsincludepercutaneousrupture,cyststeroidinjection,andsurgical resection.ImageguidedcystruptureiscommonlyperformedthroughthefacetjointbyeitherradiographyorCTfluoroscopywiththe goalsofpainrelief,cystrupture,and/orcompleteorpartialregressionofthecyst. Objectives:1.ReviewtheclinicalpresentationandimagingappearanceofLFSCsonMRIandCT.2.DiscusstheusefulnessofCTguided LFSC rupture/decompression as a minimally invasive treatment of associated radicular back pain. 3. Discuss the techniques in performing CTguided LFSC rupture/decompression. 4. Identify and understand the indications, contraindications, and potential complicationsassociatedwithperformingCTguidedLFSCintervention. Outline:1.ImagingappearanceofLFSConCTandMRIA.DiscussreportedrelationshipbetweenLFSCsignalintensityonMRimaging and outcomes as it relates to percutaneous rupture success and need for subsequent surgery. 2. Clinical presentation of LFSC 3. Overview of CT guided LFSC intervention A. Indications and Contraindications B. Techniques of the Procedure a. Preprocedure planningb.Medications(anesthetics,corticosteroids,contrastagents)c.Cystruptureversuscyststeroidinjectiond.Postprocedure imagingC.PotentialComplicationsD.AdvantagesanddisadvantagesofCTversusfluoroscopyforperformingtheprocedure Conclusions:PercutaneousCTguidedlumbarfacetsynovialcystinterventionisasafe,reliable,andreproduciblemethodoftreating symptomaticfacetcystsnonsurgically. 175 ePoster #6 ASSESSMENTOFTENDONANDTENDONSHEATHPATHOLOGYFOLLOWINGTHERAPEUTICINJECTION:THETENOSONOGRAPHIC EFFECT JenniferLMcOsker;RonaldSAdler;GinaCiavarra;RenataLaRoccaVieira;JamesBabb NYULangoneMedicalCenter (Presentedby:JenniferLMcOsker,MD) Purpose:Todeterminewhetherthedistensionofatendonsheathwithfluidimprovestheconspicuityoftendonmorphology,tendon sheaththickeningandsynovitis. MaterialsandMethods:Threemusculoskeletalradiologistsexperiencedinperformingmusculoskeletalultrasoundretrospectively reviewedatotalof39cineclipsthatwereobtainedfrom17patients(agerange=2167,13femaleand4male)bothbeforeandafter therapeuticultrasoundguidedtendonsheathinjection(6peronealtendons,10flexorhallucislongustendons,1flexorcarpiulnaris tendon).Insomecases,multiplecineclipswereobtainedforasinglepatient.Thecineclipswereanonymizedandpresentedtothe radiologistsinrandomorder,afterwhichtheradiologistswereaskedtocompletearesponseformaddressingwhetherthetendon andtendonsheathwerewelldelineated,aswellasthepresenceoftendonsheaththickening,degreeoftendonsheathdistension, tendinosis, synovitis, and a tendon tear. For each question, the radiologists were asked to provide their confidence level on a 1 (extremelyconfident)5(notatallconfident)scale.Forallquestionsinwhichtheradiologistsreportedoneofthepreviouslymentioned findings,theradiologistswereaskedtoassessthepercentageofthecineclipduringwhichthefindingwasclearlyvisualized.Statistical analysisincludedlogisticregressionandmixedmodelanalysisofvariance. Results:Foreachquestion,atleastoneradiologist’sanswerchangedaftertheinjectionoffluidintothetendonsheathinastatistically significantmanner(pvalue0.0010.049).Eachradiologist’sconfidencelevelincreasedwhenevaluatingpostinjectioncineclipsas comparedtothepreinjectioncineclips.Therewasastatisticallysignificantincreaseintheconfidencelevelofallthreeradiologists(p value<0.0010.044)whenaskedtoevaluatetheconspicuityofthetendonmarginsaswellasthepresenceofsynovitis.Therewas increasedconcordanceamongsttheradiologistswhenevaluatingthetendonsandtendonsheathsaftertheinjectionoffluid,which achievedstatisticalsignificanceforfiveoutofsevenquestions(pvalue<0.0010.049). Conclusion:Theconspicuityoftendonandtendonsheathmorphologywasimprovedafterthedistensionofthetendonsheathwith fluid. In addition, radiologist confidence level and concordance was improved on postinjection imaging when compared to pre injectionevaluation. 176 ePoster #7 NORMALSKELETALDEVELOPMENTANDIMAGINGPITFALLSOFTHECALCANEALAPOPHYSIS:MRIFEATURES IgnacioMartinRossi;ZehavaSadkaRosenberg;ChimereMbaJonas;JonathanZember;ChristopherMorley;AnnieWang NYUHospitalforJointsDiseases (Presentedby:IgnacioMartinRossi) Purpose: Familiarity with normal skeletal maturation of the posterior calcaneal apophysis, as visualized on MRI, is crucial for distinguishingitfromdiseaseentitiessuchasSever’s,fracture,avascularnecrosisandosteomyelitis.Thepurposeofthisposteristo illustrate,previouslyundescribedMRIstagesindevelopmentoftheposteriorcalcaneus,withattentiontoimagingpitfalls. Materialsandmethods:151consecutiveMRIanklestudiesin138patients(68boys,70girls,ages0<5,n=27;ages5<10,n=42;10<15, n=36andages1518,n=33)werereviewedwithspecialattentiontothedevelopmentofapophysisofthecalcanealtuberosity.The morphologyandsignalofthecartilaginousprecursor,oftheprimarycalcanealossification,ofthesecondaryossificationcentersand ofthechondroosseousjunctionweredocumentedinallcases. Results: Cartilaginous calcaneal precursor: Conformed to final shape of calcaneus, initially cartilaginous in signal but with growth depicted foci of bright and low signal possibly reflecting increased vascularity and preossification centers. Primary calcaneal ossificationcenter: Initiallynodularbut by12 years ofagedepicted similar morphology to adultcalcaneal shape. Surroundedby circumferentialbrightsignal.Signalofbonetransformed,withinfirstfewmonthsafterbirth,fromredtofattymarrow,withstarrysky appearance.Secondaryapophysealossificationcenters:Notedasearlyas5yearsofage,initiallymultiple,graduallycoalescedtocap likeapophysis.Fusionbeganasearlyas12yearsoldandwasalmostcompleteinallpatientsby15yearsofage.Signaltransformed fromredtoyellowmarrowbut4casesinthe1015depictedintenseincreasedfluidsignalsimulatingpathology.Converselyfociof intenselowsignalsuggestedavascularnecrosis.Thecaplikeapophysiswasnearlyalwaystraversedbylinearlowsignalsimulatinga fracture.Chondroosseousjunction:Therewasperipheral,circumferentialincreasedsignalatthechondroosseousjunction,witha trilaminarappearanceatthegrowthplate.Transient,lowsignalgrowthplatescarwasnotedoncefusionoccurred.Imagingpitfalls: Intense increased signal in the calcaneal apophysis, particularly in combination with nearly ubiquitous, linear, low signal line, can simulateSever’sdiseaseorastressfracture.Focioflowsignalonallpulsesequenceswithintheapophysealossificationcentersshould not be misinterpreted as avascular necrosis. Signal heterogeneity of the cartilaginous precursor and of the primary calcaneal ossification(starryskyappearance)shouldnotbemisinterpretedasdisease. Conclusion:Thedevelopmentoftheposteriorcalcaneusfollowsauniquemorphologicandsignalcharacteristics.Fusionofapophysis occursearlierthanreportedintheliterature.Familiaritywiththematurationpatternwillavoidvariousimaginginterpretationpitfalls. 177 ePoster #8 THEHIDDENSECRETSOFTHEAPRADIOGRAPHOFTHEANKLE IgnacioMartinRossi;ZehavaSadkaRosenberg;ChimereMbaJonas NYUHospitalfrJointDiseases (Presentedby:IgnacioMartinRossi) Thepurposeofourposteristoillustrate,onAPradiographoftheankle,subtleandpoorlyrecognizedosseousandsofttissuediseases, whichmaybenotedfirstoronlyonthatprojection.Overlookingtheseentitiescanleadtodelayedclinicaldiagnosisandtreatment and,attimes,significantincreasedmorbiditytothepatient. Thisposterwillbesubdividedinto2parts: 1)DiscussionofthenormalanatomyasdepictedonAPradiographoftheankle 2)Discussionofsubtlediseaseentities,whichcanbedetectedonAPviewoftheankle.Confirmationwithotherimagingmodalities suchasCTandMRIwillbeprovidedineachcase.Theseentitiesinclude: a)Fracturesofthetalarbodyandofthelateralprocessofthetalus b)Fracturesoftheanteriorprocessofthecalcaneus c)Deepandsuperficialdeltoidavulsionfractures,tears d)Flexorretinaculartearswithposteriortibialtendondislocation e)Superiorperonealretinaculartearswithsubluxations/dislocationsoftheperonealtendons f)Inferiorperonealretinaculartears g)Hypertorphiedperonealtuberclewithassociatedperonealtendondisease h)Extraarticularimpingement AfterreviewingtheposterthereaderwillbeabletodiscernosseousandsofttissuediseasesontheAPview,heraldingsignificant osseousandsofttissueabnormalities,thusprovidingguidanceregardingfurtherimagingstudiesaswellastreatmentapproach. 178 ePoster #9 CHARCOTFOOT:THESPECTRUMOFFINDINGS,WITHANEMPHASISONSOFTTISSUECHANGES SayedAli TempleUniversityHospital (Presentedby:SayedAli) PURPOSE:ToreviewtheimagingspectruminCharcotneuroarthopathy(Charcotfoot),withanemphasisonthelesswellrecognized softtissuechanges. MATERIALSANDMETHODS:Plainradiographs,radionuclidebonescans,CT’sandMRI’sof20casesofCharcotfoot(CF)obtainedat theCharcotcenterofourinstitutionwerereviewedforthefollowingsofttissuecharacteristics:softtissueedemawithorwithout bonechanges,hyperemia,softtissuelossincludingmuscularatrophy,metatarsalfatandheelpadthinning,jointeffusions,synovial outpouching,adventitialbursaeformation,Lisfrancligamentedemaorrupture,posteriortibialtendinosisortear,softtissueabscess and soft tissue ulcer incases with associated infection. Bonychanges evaluated included focal demineralization, flattening of the metatarsalheads,monoorpolyarticularinvolvement,bonedissolution,coalescenceorremodeling.Bonycharacteristicsevaluatedon MRIincludedmarrowedema,subchondralfractures,contrastenhancementandthepresenceorabsenceofthe“ghost”signincases ofsuspectedinfection. RESULTS:SofttissueswellingandjointeffusionswereseenintwocasesofearlyCharcotfoot.Subsequentthinningofthesofttissues wasseenin4of15caseswithchronicchanges,twoatthemetatarsalheadsandtwoattheheels.Jointeffusionsofvaryingseverity wereseeninall10patientswhohadMRI’s,andadventitialbursaeandsynovialoutpouchingswereseeninonecaseofchronicCF. Lisfrancligamentrupturewasdemonstratedintwocases.Posteriortendontenosynovitisandtendinosiswasseeninthreecases,and a high grade partial tear in one. A soft tissue ulcer was seen in two cases with confirmed associated osteomyelitis. Ten patients demonstrateddiffusedemineralizationintheearlystages,followedbytheclassicpatternofmidfootdisorganizationandcollapse. Soft tissue and bone contrast enhancement on MRI was seen in 7 cases. Subchondral fractures were demonstrated in one case, precedingfragmentation.The“ghost”signsuggestingconcomitantosteomyelitiswaspresentinonecase. CONCLUSION:SofttissuechangesarecommoninCharcotfoot,butunderrecognized.TheymaybehelpfulindifferentiatingCFfrom traumaticmidfootdisorganizationandcollapse(forexample,heelpadthinningassociatedwithmidfootcollapsefavorsCF).When combinedwithotherfeatures,theyarealsousefulintheevaluationforassociatedinfection.Softtissuechangesmayprecedethe moreobviousosseouschanges.Recognitionofassociatedtendonpathologyisalsousefulforpreoperativeplanning. 179 ePoster #10 POSTEROMEDIALEXTRAARTICULARCOALITION:POORLYRECOGNIZEDANDUNDERDIAGNOSEDENTITYINTHEHINDFOOT CatherinePetchprapa;ZehavaRosenberg;ElizabethCarpenter NYUHospitalforJointDiseases (Presentedby:CatherinePetchprapa) Purpose:Thisposterwillfocusonarelativelycommon,yetpoorlyrecognizedandfrequentlyunderdiagnosed,posteromedialextra articularcoalition(PMEAC)ofthehindfoot,withemphasisonnumerouscoexisting,andafewpreviouslyundescribed,osseousand softtissueabnormalities.Familiaritywiththiscoalitionanditsfrequentoverlapwiththemorecommonmiddlesubtalarcoalitionis importantwhensurgicalresectionofthecoalitioniscontemplated. Posteroutline:Theexhibitwillbesubdividedinto2parts. PartI:WillfocusonnormalsubtalaranatomyandMRIfeaturesofPMEAC.Guidelinesfordiagnosingthisoftensubtlecoalition,and recognizingitscommonoverlapwiththemorecommonmiddlesubtalarcoalitionwillbeprovided. Part II: Will illustrate concomitant frequent, as well as rare and previously unrecognized, osseous and soft tissue abnormalities associatedwithPMEAC.Completesubtalarcoalition,posteriorsubtalarcoalition,andoverlapcoalitionswillbediscussed.Coexisting soft tissue findings will include thickened subtalar fibrous bands, flexor hallucis longus and flexor digitorum longus pathology, neuropathy of the posterior tibial nerve and accessory posterior compartment muscles, including the accessory flexor digitorum, accessorysoleusandperoneocalcaneus. Summary:AttheendoftheexhibitthereadershouldhaveanenhancedawarenessofPMEACanditscoexistingsofttissueandbony abnormalities. 180 ePoster #11 FOOTARTHRODESISHARDWARE:AREVIEW TatumA.McArthur;JessicaL.Millsap;AngelA.GomezCintron;SaurabhGupta;MichaelG.Rodriguez TheUniversityofAlabamaatBirmingham(UAB) (Presentedby:TatumA.McArthur,MD) Introduction: Foot arthropathy, usually related to posttraumatic degenerative osteoarthrosis, is a common cause of pain and disability. Surgical intervention typically involves arthrodesis for correction of various causes of hindfoot, midfoot, and forefoot deformities.Thearthrodesisprocedureshaveevolvedoverthelastdecadewithchangesintechniquesanddevelopmentofmultiple surgicalapproaches. Objectives:1.Reviewtheclinicalpresentation,differentialdiagnosis,andimagingappearanceofhindfoot,midfoot,andforefootpain. 2.Discussthedefinition,imagingappearance,anddiagnosticcriteriaofpesplanus,cavovarus,equinovarus,andhindfootvarusor valgus.3.Identifyandunderstandtheindicationsandcontraindicationsforfootarthrodesis,includingidiopathicandposttraumatic degenerativeosteoarthrosis,inflammatoryarthritis,advancedposteriortibialtendondysfunction(PTTD),Charcotarthropathy,hallux rigidus,andprogressiveneuromusculardisease.4.Reviewthenormalappearanceofthepostoperativefootarthrodesishardware.5. Identifythepostsurgicalcomplicationsassociatedwitharthrodesishardware,primarilyfocusingonlooseningandfailureaswellas infection Outline:1.Radiographic,CT,andMRimagingappearanceandclinicalpresentationofpreoperativehindfoot,midfoot,andforefoot pain.2.Indicationsandcontraindicationsforfootarthrodesis3.Normalpostoperativeappearanceoffootarthrodesishardwareon radiographsandCT.4.DiscusspostsurgicalcomplicationswithradiographicandCTimagingexamplesprovided. Conclusions: Foot pain can cause significant functional limitations. Surgical interventions can provide symptom relief. Given the increasing volume of foot arthrodesis surgeries performed in everyday practice, it is imperative that the radiologist identify and understandthenormalandabnormalimagingappearanceofthepostoperativefoot. 181 ePoster #12 POSTERIORTIBIALTENDONDYSFUNCTION,THESPRINGLIGAMENT,ANDACQUIREDPESPLANUS TatumA.McArthur;AngelA.GomezCintron;AnandPatel;MichaelG.Rodriguez TheUniversityofAlabamaatBirmingham(UAB) (Presentedby:TatumA.McArthur,MD) Introduction:Posteriortibialtendondysfunction(PTTD)isthemostcommoncauseofacquiredpesplanusinadults.Attenuationor ruptureofthespringligamentcomplexincludingthetalonavicularcapsulecanhaveasimilarclinicalpresentationasposteriortibial tendon dysfunction. Patients with PTTD demonstrate extensive ligament involvement, particularly the springligament complex. KnowledgeoftheimagingappearanceofPTTDandspringligamenttearsinthedevelopmentofpesplanushasclinicalimplications. Objectives:1.Reviewthenormalanatomyoftheposteriortibialtendonandspringligament.2.Reviewtheclinicalmanifestations and presentation of acquired pes planus. 3. Discuss the abnormal appearance of the spring ligament, specifically focusing on degenerativetearsofthespringligamentassociatedwithPTTDonMRI,whichproducesacquiredpesplanusdeformity.4.Reviewthe diagnosticcriteriaandimagingappearanceofpesplanusonradiographs,CT,andMRI.5.Discussthenonoperativeandoperative treatmentofacquiredpesplanus,aswellasindicationsforsurgicalintervention. Outline:1.Normalanatomyofthespringligamentandposteriortibialtendon2.Clinicalpresentationofacquiredpesplanus3.Imaging appearanceofspringligamenttearsassociatedwithPTTDonMRI4.Imagingappearanceofpesplanusonradiographs,CT,andMRI. 5. Nonoperative and operative treatment of acquired pes planus. a. Nonoperative treatment b. Surgical indications c. Surgical contraindicationsd.Surgicalcomplications6.Normalpostoperativeappearance Conclusions:Earlyrecognitionandtreatmentofposteriortibialtendondysfunction,springligamenttears,andacquiredpesplanusis keytothepreventionoflongtermconsequences.Itisimportantfortheradiologisttoknowandunderstandthediagnosticcriteria, radiologicappearance,treatment,andnormalpostoperativeappearanceforoptimalpatientcare. 182 ePoster #13 “LEOPARDSPOTEDEMA”:ANOSSEOUSSTRESS,HEALINGANDREINJURYPHENOMENONINPROFESSIONALBALLETDANCERS SEENONMR FelixGonzalez;BethanyCasagranda;PhilipColucci;JohannesRoedl;WilliamB.Morrison;AdamZoga ThomasJeffersonUniversityHospital (Presentedby:FelixGonzalez,M.D.) Introduction: Professional ballet dancers are subject to numerous overuse syndromes about the ankle and foot. Anecdotally, we observedapatchybonemarrowpatternonMRinthehindfeetofskeletallymaturedancers,similartothe“starrynight”pattern describedasnormalinchildren.Wesoughttodescribethispatternof“leopardspotmarrowedema”(LSME)atMRandexploreits potentialetiologyandsignificanceusingclinicalcorrelationandfollowupimaging. MaterialsandMethods:28MRexamsoftheankle/hindfootin19professionalballetdancerswerereviewedby2MSKradiologists. The presence of LSME was recorded along with age, gender, clinical indication and primary MR findings potentially related to symptoms.FollowupMRswerereviewedandedemawasgradedasimprovedorprogressive.Correlationwithclinicalfindingswas made. Results:LSMEwasobservedin14/18subjects(78%)and22/28MRs(78.5%).8/22withLSMEhadrepeatMR(interval371,mean33 months).5/8showedimprovementofLSMEincluding2withcompleteresolution,bothofwhomwerenotdancingatfollowup.1 subjectshowedimprovementat5monthsbutprogressionat24months.3/8hadprogressiveLSME,andall3weredancinginanactive productionatfollowup.ForsubjectswithLSME,theagerangewas2235,mean25years.Therewaslittlegenderdifferenceas9/11 femalesand5/7maleshadLSME.AsforotherMRfindings,9/18(50%)hadfocalosseousstressresponseorstressfracture,7/18(39%) hadfindingsofposteriorimpingement,2hadlateralligamentinjury,2hadposteriortibialtendoninjury,and1eachhadAchilles tendinopathy,Lisfrancsprainandperonealtendinopathy.2subjectswithLSMEat1stMRhadstressfracturesatfollowup. Conclusions:“Leopardspotmarrowedema”isacommonbutpreviouslyunreportedfindingatMRofthehindfootinballetdancers, and our series suggests progression with active dancing such that it may reflect a syndrome of microtrabecular injury, healing response,andreinjurydistinctfromthepediatricmarrowpatternreportedasnormal. 183 ePoster #14 POSTERIORTIBIALDYSFUNCTION:IMAGINGDIAGNOSISWHENNOMRIDETECTABLETENDONPATHOLOGYISPRESENT ElieHarmouche;DouglasRobertson;AparnaKakarala;SethMeans;MinzhiXing;MichaelTerk GeorgiaInstituteofTechnology,DepartmentofBiomedicalEngineering (Presentedby:ElieHarmouche) Introduction:Theposteriortibialtendon(PTT)iscoveredbyatendonsheaththatextends1to2cmproximaltothenavicularinsertion. Diagnosis of PTT dysfunction is based on history and physical exam, with magnetic resonance (MR) imaging commonly used for confirmation. It may be present without intrasubstance tendon pathology. The association of tendon sheath fluid with PTT dysfunctionhasnotbeenstudied.Thepresenceofminimalfluidinthetendonsheathisconsiderednormalbysomeandabnormalby others.InindividualswithmedialanklepainandPTTsheathfluidbutnoMRIdetectableintrasubstancetendonpathology,sheath fluidmaybegreaterinthosewithaclinicaldiagnosisofPTTdysfunction. Methods: Five hundred and forty MRIs performed for medial ankle pain were retrospectively screened for PTT sheath fluid. One hundredandtwoankleswereidentified.Threeobservers,blindedtoclinicaldiagnosis,independentlyassessedtheidentifiedankle MRIs.AllcaseshadPTTsheathfluidbutnoMRIdetectabletendonpathology.TwentyfourindividualshadaclinicaldiagnosisofPTT dysfunction with alternative diagnoses for the remaining 78 (controls). Sheath fluid was assessed from the tibial plafond to the navicular bone. Geometric methods defined sheath fluid volume, maximum crosssectional fluid area, and maximum fluid width. Tendon sheath fluid volume, area, and width were compared between the PTT dysfunction group and controls. Inter and intra observermeasurementreliabilitywascalculated. Results:TherewasasignificantdifferencebetweenindividualswithclinicaldiagnosesofPTTdysfunctionandcontrolsinsheathfluid volume,maximumcrosssectionfluidarea,andmaximumfluidwidth(pvalues<0.01).Athresholdmaximumfluidwidthof8mmwas associatedwiththeclinicaldiagnosisofPTTdysfunction(specificity95%,negativepredictivevalue82%) Conclusions:InindividualswithmedialanklepainandnoMRIdetectableintrasubstancetendonpathology,PTTsheathfluidwhether measuredasavolume,area,orwidthwasgreaterinthosewithaclinicaldiagnosisofPTTdysfunction.Wesuggestmeasurementof maximum sheath fluid width (> 8mm) on axial MR images as a quick additional assessment when PTT dysfunction is considered. Significance:TheseresultsexpandourknowledgeoftheclinicalrelevanceofPTTtendonsheathfluidinPTTdysfunction.Whenthere isnoMRIdetectableintrasubstancetendonpathology,PTTsheathfluidmeasurementwhetherasavolume,area,orwidthisgreater inindividualswithaclinicaldiagnosisofPTTdysfunction. 184 185 ePoster #15 MRIANDCLINICALEVALUATIONOFACCESSORYNAVICULARBONETYPES JadChamieh;SimaBanerji;DouglasRobertson;ElieHarmouche;SamehLabib;MichaelTerk EmoryUniversity (Presentedby:JadChamieh) Purpose:ConventionalwisdomisthatonlytypeIIaccessorynavicularbonesareclinicallyimportant.WehypothesizethattypesIand IIImayalsoleadtosignificantclinicalconsequences. Methods:AretrospectivestudyofMRIexaminationson135individualswithaccessorynavicularboneswasperformed.Weevaluated allthreeanatomicaltypesandtestedtheirassociationswithfocalpain(atthenavicular),pesplanus,ossicleorproximalnavicular bone marrow reactive change (BMRC), and posterior tibial tendon (PTT) sheath fluid. Twentyseven percent (27%) of studied individualshadtypeI,60%typeII,and13%typeIIIbones.Twoobserversrecordedtheimagingfindingsandintraandinterobserver MRIfindingreliabilitywastested. Results:Ageandgenderwerenotstatisticallydifferentbetweenbonetypes.TwentyeightpercentoftypeI,42%oftypeII,and6%of typeIIIaccessoryboneshadfocalpain(typeIversusII,p=0.17;typeIIIversustypeII,p=0.011).ThirtypercentoftypeI,40%typeII, and6%typeIIIaccessoryboneshadconcomitantpesplanus(typeIversusII,p=0.39;typeIIIversustypeII,p=0.017).Eightpercentof typeI,47%oftypeII,and6%oftypeIIIaccessoryboneshadBMRC(typeIversusII,p<0.0001;typeIIIversustypeII,p=0.007).Thirty onepercentoftypeI,42%oftypeII,and6%oftypeIIIaccessoryboneshadPTTsheathfluid(typeIversusII,p=0.29;typeIIIversus typeII,p=0.011).MRImeasurementswerereliable. Conclusions:AllthreetypesofaccessorynavicularboneswerestudiedandtypeIIboneshadthehighestprevalenceofsymptomsand findings;however,thesymptomsandfindingsoftypeIboneswerenotstatisticallydifferentthantypeIIbones,exceptforlessBMRC inthesmalltypeIossicles.ThisdemonstratesforthefirsttimethattypeIaccessorynavicularboneshavesymptomsandfindings similartotypeIIandprobablywarranttreatmentconsiderationandconfirmsthattypeIIIbonesmaybeleftalone. 186 ePoster #16 ULTRASOUNDANDMUSCLE:AMATCHWITHLONGTERMPOTENTIAL MichelleMcNee;BenjaminLevine;BenjaminPlotkin;KambizMotamedi;JordanGross UniversityorCaliforniaLosAngeles (Presentedby:MichelleMcNee) Objective:Ultrasoundisparticularlywellsuitedforassessmentofmusclepathologyformanyreasons.Duetocontinuallyimproving ultrasoundtechnology,andinahealthcaresysteminwhichcostisincreasinglyadriverofclinicalanddiagnosticdecisionmaking,itis likelythatutilizationofthismodalityintheevaluationofmusclewillcontinuetoincreaseinprominenceandpopularity.Thepurpose ofthisstudyistoprovidebothaguidelineforultrasoundimagingtechniquesthatoptimizeassessmentofmuscles,aswellastopresent apictorialreviewofthetypesofmusclepathologyideallyidentifiedandevaluatedbythismodality. Methods:Utilizingcasesofmusclepathologiesencounteredatourinstitution,wewilldemonstratetherangeofdiagnosticentities andcategoriesofdiseasewhichcanbeassessedusingultrasound,whilesimultaneouslydescribingtheirimagingfeatures.Where appropriate,examplesofcorrelationswithothermodalities,primarilymagneticresonanceimaging(MRI),willbemade.Thenormal appearance of muscle on ultrasound will also be presented, as will the specific ultrasound techniques we have found, in our experience,toyieldimagesofgreatestdiagnosticutility. Results:Illustrativeexampleswithinfourgeneralcategoriesofmusclepathology(trauma,edema/hyperemia,fluidcollection,and mass)arepresentedwithpertinentfindingshighlightedanddiscussed.Unifyinggeneralprincipleswithbroadapplicabilityinmuscle ultrasoundinterpretationarealsointroduced.Caseswithavailablecorrespondingimaginginothermodalitiesareusedtoillustrate how ultrasound compares to its alternatives in identifying and characterizing findings. Images of normal muscle appearance and architecturearealsopresentedasabasisforrecognizingpathology. Conclusions: For many diseases and pathologies affecting muscles, ultrasound provides an accurate, and in many cases superior, imaging modality for investigation when compared to the primary alternative, namely MRI. Given the additional advantages of ultrasoundintermsofcost,convenience,andavailability,itmaybecomeincreasinglyimperativeformusculoskeletalradiologiststo beadeptatperformingandinterpretingultrasoundimagesofmuscle. 187 ePoster #17 INTRAARTICULARPATHOLOGYASSOCIATEDWITHISOLATEDPOSTERIORCRUCIATELIGAMENTTEARS EzekielE.Shotts;MarkS.Collins;MichaelD.Ringler;B.MatthewHowe MayoClinic (Presentedby:EzekielE.Shotts) Purpose:Toidentifypatternsofmeniscaltear,cartilageinjury,subchondraledema,andfractureassociatedwithisolatedtraumatic tearsoftheposteriorcruciateligamentoftheknee.Background:IsolatedinjuriesofthePCLarerelativelyrare.Relativelyfewstudies haveinvestigatedanassociationofmeniscaltearwithisolatedPCLinjuries. MaterialsandMethods:IRBapprovalwasobtainedandelectronicdatabasesearchwasperformedforpatientswithisolatedPCLtears presentingfrom4/1/20044/1/2014.Exclusioncriteriaincluded:Ageover40,osteoarthritisonkneeradiographs(KellgrenLawrence gradeIIandabove),priorkneesurgery,kneepainpriortoPCLinjury,andmultiligamentoushighgradetears.TwoMSKfellowship trainedradiologiststhenreviewedinconsensustheMRIfindingsin48separatecasesofisolatedPCLtears,evaluatingthelocation andtypeofmeniscaltear,locationofcartilageinjury,locationofsubchondraledema,andlocationofanyfractures. Results:Ofthe48PCLtears,17werecompletetearsand31werepartialtears.Midsubstancetearswerethemostcommonlocation ofinjury,accountingfor69%ofcases.DistaltearsandosseousavulsionsweretherarestPCLteartype,withonly1caseofeachinour cohort.Proximalinjuriesaccountedfortheremaining27%.Twelveof48cases(25%)hadameniscaltear.Nineoutofthe13meniscal tearsinvolvedtheposteriorhornorrootofeitherthemedialorlateralmeniscus,andfourofthesecaseswereradialtypetears.The anteriorhornofthelateralmeniscuswastornin3cases.Bonemarrowedemamostcommonlyoccurredintheanteriormedial(15/48 cases)andlateral(11/48cases)tibialplateau.Edemawaslesscommoninthefemoralcondylesandinthepatella.Fracturesaboutthe kneeweremostlikelytoinvolvethetibialplateau(6/48cases),withtheanteromedialtibialplateaubeingthemostcommonlocation tobeinvolvedwiththefracture(4/6).Therewasonlyonecaseofafemoralfracture,whichwaslocatedinthelateralfemoralcondyle, andtherewerenopatellarfractures.Cartilagelesionsmostcommonlyinvolvedthefemoralarticularsurfaces,withthemedialfemoral condyleaccountingforthemostofthelesions(6cases,allwithgreaterthan50%cartilageloss).Thecentraltrochleawasthesecond mostcommonlocationforcartilageinjury,with5totalcasesincluding4with100%cartilageloss.Therewascartilageinjurytothe patellain6cases,buttherewasnopredominatelocationofinjury.Tibialcartilageinjurieswererare,onlyoccurringinonecase.The posteriorlateralfemoralcondyleandlateraltrochleawerenormalinallcases.Themedialtrochleawasonlyinjuredinonecasewere therewasacartilageinjurywithlessthan50%cartilageloss. Conclusion: Isolated PCL tears are commonly associated with meniscal tears, cartilage injuries, fractures, and microtrabecular fracture/bone marrow edema. Awareness of the most common appearance and location of these injuries is important since the presenceoftheseconcomitantfindingsmayalterpatientmanagement. 188 ePoster #18 MEDIALMENISCALPROTRUSIONETIOLOGY:DEEPMEDIALCOLLATERALLIGAMENTINSUFFICIENCYISMORESTRONGLY ASSOCIATEDTHANROOTLIGAMENTINJURY PaulWeatherall,MinaHanna,LoweryReiland,GinaCho,HythemOmar,BrianCox,DanMoore UTSouthwesternMedicalCenter (Presentedby:PaulT.Weatherall,MD) Purpose:Provethatinobeseindividuals,deficiencyofasinglecriticalcomponentofmedialcollateralligament(MCL)–thetibial attachmentofdeepMCL(dMCL)isstronglyassociatedwiththedegreeofperipheralmigrationofthebodyofthemedialmeniscus, toagreaterdegreethanseenwithmeniscalrootinjury. MaterialsandMethods:Patients(n=76,ages2364yo)withBMI35andkneesymptoms,butnorecentmedialkneetraumaand intactsuperficialMCL.MRIfatsuppressedprotondensityimages(4mmx0.6mmpixel).Measurement(+/0.1mm)andMRIsignal(0 4scale)evaluationby4MSKtrainedradiologists(dataaveraged).AssessmentincludeddMCLzone(mmbetweentibiaandsuperficial MCL)andsignal;medialmeniscusprotrusion(peripheralmigrationofbody);meniscussignalwithinanteriorandposteriorhornsand root ligaments (separately). Higher dMCLzone signal and greater meniscal signal/area involvement were considered to be more pathologic.PairedrelationshipsofmeniscusprotrusionanddMCLfeatures,versusmeniscalrootinjury,wereassessedusingPearson correlationanalysis. Results/Discussion:StrongcorrelationbetweendMCLregionabnormalitiesandmedialmeniscalperipheralmigration:Lessstrong associationofmeniscalrootligamentandhorninjury. Table1(Pearsoncorrelations)MENISCALPROTUSION dMCLwidth dMCLSignal MenRootSignal MenRoot +HornsSignal 0.897 0.607 0.443 0.489 Prematureosteoarthritisnearlyalwaysfollowslossofnormalmeniscusvolumeorposition.Coronaryligamentsareaprimaryanchor formeniscalattachmenttotibialplateau.SotheextremelystrongassociationbetweendMCLzonewidthandperipheralmeniscal migrationwasexpected.Inobesepatientschronicincreasedmechanicalhoopstressonthemeniscusattachmentfibers,resultsin insufficiency/laxityofthissegmentofcoronaryligaments.OursurrogatefordMCLinjuryisincreasedsignalonfatsuppressedfluid sensitiveimages.HigherdMCLsignalstronglycorrelatedwithmeniscalprotrusion.Disruptionofcentralmeniscalattachmentsalso leadstoperipheraldeviation,asreportedbymultipleotherinvestigators.Ourdataconfirmsthisassociationofmeniscalprotrusion withrootligamentdisruption,buttoamuchlesserdegree.Wealsocombinedrootligamentand/orsignificantanteriorposteriorhorn injuryinonesubsetof36patientsktau=0.551)withtheresultbeingadefinitelystrongerassociationwithprotrusion.However,the meniscalinjury/protrusioncorrelationwasstillwellshortofthatseenwithdMCLsignalabnormality. Conclusions:1.Medialmeniscusprotrusionismuchmorestronglyassociatedwithperipheralcoronaryligamentinjury/insufficiency comparedtoinjuryoftherootligaments.2.Confirmationofaspecificstructuralcauseofprematureosteoarthritisinobesepatients willallowdirectedtherapyandpotentiallydelaymorbidityandexcesscostsrelatedtothisdisease. 189 Figure1:MeniscalProtrusion–IntactRootLigaments 190 ePoster #19 LYTICVSSCLEROTICBONELESIONS:DIAGNOSTICACCURACYOFCTGUIDEDCOREVSFNABIOPSYTECHNIQUES JadChamieh;BinduAvutu;WalterCarpenter;DouglasDRobertson;AparnaKakarala EmoryUniversitySchoolofMedicine (Presentedby:JadChamieh) Purpose:CTguidedneedlebiopsyforprimaryormetastaticbonelesionsisanaccurateandlessinvasiveapproachthantraditional opensurgicalbiopsy.However,conflictingdataexistsintheliteratureconcerningitsdiagnosticyieldinbothlyticandscleroticlesions. Inaddition,nostudyhascomparedCOREtoFNAdiagnosticaccuracyonthesamelesion.Thepurposeofthisstudyistotestthe diagnosticyieldofCOREversusFNAbiopsyandrelateittolesiontype,size,locationandpathology. Methods:CTguidedbonebiopsiesperformedbetweenJanuary2013andJune2014atourinstitutionwereincludedinthestudy. Onlylyticorscleroticlesionswithconcernforneoplasiawereconsideredandthosewithosteomyelitisorsofttissueinfectionand mixedtypewereexcluded.Fiftyone(51)females(meanage61years±13.75,range2786)and63males(meanage60.4years±13, range1982)wereincludedinourpopulation.Electronicmedicalrecordswerereviewedandinformationonlesiontype,location,size, typesofneedlesused,diagnosticyield,primarytumorandpathologicaldiagnosiswerecollected.Statisticalanalysiswascarriedout with SPSS through a chisquare test. A binary logistic regression model was created that predicted the relationship between the diagnosticyieldandthecombinedeffectsofage,gender,finaldiagnosis,COREorFNAused,andlesionsize,typeandlocation. Results:Averagelesionsizewas23mm±15,range371mm.Overalldiagnosticaccuracywas81.6%,with79.4%forCOREand43.4% forFNA.IncaseswherebothFNAandCOREweredone,COREwasdiagnosticin81.3%comparedtoFNAat32.8%,pvalue0.045.None ofthescleroticlesionshadadiagnosticFNAwherebyCOREwas71.4%diagnostic.TherewasonlyonecaseinwhichFNAwasdiagnostic andCOREwasnot.Thestatisticalmodelshowedthatonlygenderandfinallesionpathologyaffectthediagnosticyieldwithpvalues 0.049and0.018,respectively.COREbiopsywithneoplasticlesionsis85%diagnosticcomparedtobenignlesionsat63.6%,p=0.025. ForFNA,itis90.5%versus53.8%diagnostic(p=0.001),respectively. Conclusion: When both are performed, diagnostic yield is higher with CORE compared to FNA, especially for sclerotic lesions. Diagnosticyieldisalsohigherinthepresenceofneoplasia.Wenowrecommendwhenimmediatepathologicalreviewisunavailable aCOREbiopsybeperformed. 191 ePoster #20 AREVIEWOFSOFTTISSUELESIONSTHATFREQUENTLYDEMONSTRATELOWT1ANDT2WEIGHTEDSIGNALONMAGNETIC RESONANCEIMAGING JonellePetscavageThomas;EricA.Walker;SangeetaChaudhary PennStateMiltonS.HersheyMedicalCenter (Presentedby:JonellePetscavageThomas) Background information/purpose: Prominent areas of low T1W and T2W signal within soft tissue lesions can be due to areas of calcification,fibroustissue,andhemosiderin.Theselesionsincludebenignentitiessuchascalcificmyonecrosisaswellasmalignant entities,anexamplebeingfibrosarcoma.Thepurposeofthisexhibitisto1)discusslesioncomponentsthatmayreveallowsignalon magneticresonance(MR),2)reviewtheMRimagingcharacteristicsofsofttissuelesionswithprominentareasoflowsignalintensity onT1WandT2Wsequences,3)emphasizeimagingfeaturesthatmaysuggestthediagnosis. Educational goals/teaching points: • Understand what components of a lesion result in low signal on T1W and T2W images • Recognizesalientimagingfeaturesthatdifferentiatebetweentheselesions•ProvidedifferentialdiagnosisforlesionswithlowT1W andT2Wsignal Results: MR images with ultrasound and computed tomography correlates will be provided of the following softtissue lesions: desmoidtypefibromatosis,pigmentedvillonodularsynovitis(PVNS)/giantcelltumorofthetendonsheath(GCTTS),elastofibroma, granularcelltumor(image),desmoplasticfibroblastoma,denselycalcifiedmasses,andfibrosarcoma. Conclusion: Soft tissue masses with prominent areas of low T1W and T2W signal include both benign and malignant entities. Recognition of the salient imaging features is vital to providing a meaningful radiological interpretation, preventing unnecessary biopsy,andguidingmanagement. 192 ePoster #21 UTILITYOFDUALENERGYCTVIRTUALNONCALCIUM(DECTVNCA)TECHNIQUEINMUSCULOSKELETALIMAGINGINTHEACUTE ANDSUBACUTESETTING GavinMcKenzie;KatrinaGlazebrook;ErinMoran;ShuaiLeng;CynthiaMcCollough MayoClinic (Presentedby:GavinMcKenzie) Objective:TohighlighttheutilityofDualEnergyCTVirtualNonCalcium(DECTVNCa)techniqueinmusculoskeletalimaginginthe acuteandsubacutesetting Background: Bone marrow edema is a useful direct or indirect sign for an indicatorof acute or subacute osseous pathology. The presenceofbonemarrowedemaisanonspecificbutsensitiveandhelpfulsignfordetectinganactiveormoresinisterosseousprocess. Bonemarrowedemacanbeseeninamyriadofpathologicprocessessuchasinfarct,neoplasm,inflammatory,infectiousortraumatic etiologies. Traditionally, edema is characterized on MRI. However, Dual Energy CT Virtual Non Calcium (DECT VNCa) imaging has receivedwidespreadattentionoflate.DualEnergyCTutilizestwodifferentpartsoftheenergyspectrumofxrays,usuallyat80and 140kVp.Byusingattenuationdifferencesatthe2differentxrayenergyspectra,calciumandnoncalciumstructurescanbediscerned. Postprocessingremovescalciumstructures,lendingtoevaluationofbonemarrowandmicrotrabeculae.AdvantagesofCToverMR includerapidacquisition,easyaccessatmostimagingcenters,cost,providedetailedcharacterizationofosseousstructuresandare usefulinthosepatientswhohaveMRIcontraindications.Moreimportantly,DECTbydetectingmarrowedemacanidentifyanactive process which would have otherwise been occult, without the need for additional imaging, specifically MRI. Earlier detection of pathologycanleadtomoretimelycareandmanagement. Teaching Points: Recent work on DECT includes uses in evaluation anddetection of acuityof non tumoral vertebral compression fractureswhencomparedtoMRIasthegoldstandard.AdditionalworkincludesdetectionofradiographicallyandSingleEnergyCT occultundisplacedhip,kneeandanklefractures,whichdemonstratedbonebruises,thusidentifyingandclarifyingthesourceofthe patient’spain.EvaluationofposttraumaticbonebruisesaboutthekneeusingDECTVNCaimagingalsoshowedthatbonebruisescan beidentifiedupto10weeksaftertheinjury,andfurthermore,giventhepatternofbonebruisesmaykeytheimagerintopossible internal knee derangement. DECT imaging of the hip was also shown to suggest more aggressive processes other than fracture including AVN. Several of these studies have demonstrated high sensitivity and specificity and negative predictive value when comparedtoMRIindetectingbonemarrowedema.Thistechniquemaythereforeplayaroleinrulingoutacuteosseouspathology whileobviatingtheneedforMRI.DECTmayalsoreadilydemonstratebonemarrowedema,thusservingasanadvocateforearlier MRI,ormoreaggressiveandtimelypatientmanagement. Conclusion:DualEnergyCTVirtualNonCalcium(DECTVNCa)imagingisanefficient,rapidtechniquewhichcanbeusedinavarietyof clinical scenarios. It can identify occult processes and provide more information compared to standard Single Energy CT and radiographs.ItcancharacterizebonemarrowedemaandguidepatientmanagementsimilartomarrowedemaonMRI,withoutthe needforadditionalcrosssectionalimaging.DECTcanleadtoearlierdetectionofpathology,thusleadingtomoretimelymanagement, andpreventingfurthermorbidity. 193 ePoster #22 REDUCERADIATIONDOSEONLUMBARSPINECTUSINGLEANPRINCIPLES ByronY.Chen;StevenJ.Baccei;ChristopherCerniglia UMassMemorialMedicalCenterandUMassMedicalSchool (Presentedby:ChristopherCerniglia) Background:Atourinstitution,averagedoseforalumbarspineCTwasapproximately50%higherthanreferencevaluesovera5 monthperiod.Inparticular,17caseshaddosesexceeding25mSvandthesealloccurredinobesepatients.Automaticexposurecontrol isatechnologywhichmodulatestubecurrentdependingonpatientsize.Howeverinlargerpatients,thetechnologymayoverdose patients,whichcanultimatelyleadtoexcesscancerrisk. Purpose: Reduce average dose on lumbar spine CT’s to 11mSv and eliminate all cases with doses exceeding 25 mSv, all while maintainingdiagnosticimagequality. Materialsandmethods:Ataskforcewasassembledincludingradiologists,physicists,andtechnologiststoexamineradiationdoses. DosesfromlumbarspineCT’sacquiredonaGE32sliceLightspeedscannerwereincluded.UsingLEANprinciples,arootcauseanalysis wasperformedandcountermeasuresdeveloped.Anupperlimitofallowablemodulationfortheautomaticexposurecontrolwasset. Dosewasrecordedpriortoandafterimplementation.3fellowshiptrainedmusculoskeletalradiologistswerepolledonimagequality beforeandafterimplementation. Results:5monthspriortoimplementationofourcountermeasures,averagedoseforalumbarspineCTwas15.5mSv.2monthsafter implementation,averagedosewasreducedto12.5mSvandthenumberofcasesexceeding25mSvwasreducedtozero.Pollingof musculoskeletalradiologistsshowednonoticeablechangeinimagequality. Conclusion:Duringa5monthperiod,radiationdosesonlumbarspineCT’swasfoundtobe50%higherthanreferencevalues.Root causeanalysisshowedthatautomaticexposurecontroltechnologywasoverdosingobesepatients,resultinginacohortwithexcessive doses(exceeding25mSv).UsingLEANprinciples,countermeasureswereimplementedresultingin19%reductionofoveralldoseand entirelyeliminatingthenumberofcaseswithdosesexceeding25mSv.Throughoutthedosereductionimplementation,diagnostic imagequalitywasmaintained. 194 195 ePoster #23 SODIUMFLUORIDEPET/CT:POTENTIALSANDPITFALLSFORMUSCULOSKELETALRADIOLOGISTS BehrangAmini;UsamaSalem;EricM.Rohren TheUniversityofTexasM.D.AndersonCancerCenter (Presentedby:BehrangAmini) Background:Fluorine18labeledsodiumfluoride(18FNaF)isarelativelyoldboneseekingagentthatoffersmanyadvantagesover themorecommonlyused99mTc–methylenediphosphonate(MDP),especiallywhencombinedwithCTimaging.Theseincludehigher resolution,greatersensitivity,andtheabilitytocorrelatefunctionalandanatomicimaging.Forthesereasons,hybrid18FNaFPET/CT isexperiencingrenewedinterest,notonlyinoncologicalimaging,butalsoinfracturehealinganddegenerativediseases. EducationalGoals/TeachingPoints:Afterreviewofthiseducationalexhibit,thelearnerwillunderstandthetheoreticalunderpinnings, potentialapplications,andcommonlyencounteredpitfallsof18FNaFPET/CT. Conclusion:Familiaritywiththepotentialsandpitfallsof18FNaFPET/CTwillbevitalformusculoskeletalradiologists,whetherthey aredirectlyinterpretingthesestudies,usingthemforcomparisonorcorrelation,orservingasconsultantstononskeletalimaging specialistsorclinicians. 196 ePoster #24 BONEANDSOFTTISSUE"TUMORMIMICKERS":IT'SNOTALWAYSNEOPLASTICDISEASE! JordanGross;MichelleMcNee;BenjaminLevine;BenjaminPlotkin;KambizMotamedi;LeanneSeeger UniversityofCaliforniaLosAngeles (Presentedby:JordanGross) Purpose:Tocharacterizethemostcommon“tumormimickers”or“pseudotumors”inourweeklymultidisciplinarysarcomatumor boardcases.Toidentifythemostcommontypesofnonneoplasticdiseasethatcanmimicsofttissueorboneneoplasia. MaterialsandMethods:Weusedourmultidisciplinarysarcomatumorboardpatientlistsoveraperiodof9monthsin2010,inorder toanalyzetheindividualpathologiesfromourweeklyconference.Intraabdominalandintrapelviclesionswereexcluded.Lesions wereonlyincludedifadefinitivepathologicdiagnosiswasmade,eitherbybiopsyorsurgicalexcision.Weseparatedthelesionsinto benignandaggressiveappearingcategories.Thebenignlesionswerefurthersubdividedintoneoplasticandnonneoplasticdisease. Wethenstratifiedtheselesionsbydemographicsaswellasthelocationofthetumor. Results:Therewereatotalof285lesionsthatwereinvestigated:164wereaggressiveappearingneoplasmsand121werebenign lesions.Oftheaggressivelesions,98patientsweremaleand66werefemale.Ofthebenignlesions,65weremaleand56werefemale (55maleand43femaleofbenignneoplasticdisease;10maleand13femaleofbenignnonneoplasticdisease).Theaverageagefor patientswithaggressiveneoplasticdiseasewas48.7years.Theaverageageforpatientswithbenignlesionswas37.3years(37.3for patients with benign neoplastic disease; 37.1 for patients with benign nonneoplastic disease). Of the benign lesions, 98 were neoplastic and 23 were nonneoplastic disease. The nonneoplastic lesions included: 8 cases of bone fragments, cartilage and/or fibroadiposetissue(2fractures,1metabolicbonedisease,1heterotopicossification,1exostosis,1nonspecificscleroticlesion,1 fibroticmarrow,1fatnecrosis),5casesofchronicosteomyelitis,5casesofnodularsynovitis,2nodularfasciitis,1ischemicfasciitis and2hematomas.Fornonneoplasticdisease,themostcommonlocationwastheknee,inwhich4outofthe5casesofnodular synovitiswerelocated. Conclusion: The most common "tumor mimickers," or “pseudotumors”, at our institution were bone fragments, most often representing fractures or nonspecific sclerotic lesions, chronic osteomyelitis and nodular synovitis. These tumor mimickers constituted about 8% of all lesions investigated. It is important to consider these types of lesions when evaluating the imaging appearanceofboneandsofttissuemasses. 197 ePoster #25 PEARLSANDPITFALLSOFNAFPETMRIINTHEEVALUATIONOFPROSTATECANCERPATIENTSFOROSSEOUSMETASTATICDISEASE TaylorJ.Stone;LuisS.Beltran NewYorkUniversityLangoneMedicalCenter/HospitalforJointDiseases (Presentedby:TaylorJ.Stone) Purpose:ToprovideouralgorithmofhowtoreadNaFPETMRIaswellasapictorialreviewofbonemetastasesandbenignbone lesionsonNaFPETMRIincludingadiscussionofthelimitationsofeachmodalityinordertoassistradiologistsandnuclearmedicine physiciansinmaximizingtheirdiagnosticaccuracy. MaterialsandMethods:AnalgorithmdepictingthewayNaFPETMRIisreadatourinstitutionwasdesignedwithspecificcasebased examples.Apictorialreviewofbonemetastasesandbenignbonelesionsinsubjectswithmetastaticprostatecancerwasperformed usingNaFPETMRIincludingPET,DWI(bvaluesof50and800),andanatomical(T1/T2STIR)MRimages.ThelimitationsofNaFPET MRIwerealsodiscussed. Results:21metastaticlesionsand15benignbonelesionswerereviewed.Numerousbenignlesionetiologieswereincluded,including a hemangioma, dental disease, degenerative vertebral endplate changes, enthesopathy, and a benign compression fracture. The limitationsofPETMRIincludedthepossibilityforovercallingmetastaticlesionswhenusingPETaloneandthelowspatialresolution ofMRIforsmallriblesions,makingdifferentiationbetweenbenignandmetastaticriblesionsindeterminate.Theonlylesionsinour studythatweremissedonPETMRIweretheriblesions,whichwereseenonPET,butnotMRI. Conclusion:Wehopethatthispictorialreviewcanassistradiologistsandnuclearmedicinephysiciansinmaximizingtheirdiagnostic accuracy when interpreting NaF PETMRI studies, particularly in differentiating between metastatic and benign bone lesions. Our algorithm should provide a basic starting point to any radiologists who will be interpreting these studies. Accurately defining the numberoflesionshasimportanttreatmentimplicationsasprostatecancertreatmentisgenerallybasedondiseaseburden. 198 ePoster #26 NOTHINGGOODHAPPENSINTHEFIBULA:IMAGINGDIFFERENTIALOFFIBULARTUMORS ScottSchiffman;ValeriyKheyfits;GregoryDieudonne;JohnnyMonu UniversityofRochester (Presentedby:ScottSchiffman) Tumorsofthefibulaarerareaccountingfor2.4%ofprimarybonetumors.Thefibulaisoftenconsideredaquiescentboneoftenused forthepurposesofbonegraftinghoweverwhenlesionsarefoundinthefibulatheytendtoconfoundtheradiologist.Imagingfindings oflesionsinvolvingthefibulaonplainradiographyandMRIcanhelpnarrowthedifferentialdiagnosisanddirectsurgicalplanning/ clinicaldecisionmaking. The differential diagnosis of a lesion involving the fibula may include giant cell tumor, aneurysmal bone cyst, osteochondroma, chondroblastoma, enchondroma,chondrosarcoma, desmoplastic fibroma, osteoblastoma,nonossifying fibroma,unicameralbone cystsorintraosseousganglioncysts.MoreaggressivetumorssuchasEwing’ssarcoma,osteosarcomaorlymphomacanalsoinvolve thefibula. Aretrospectivekeywordbasedreviewwasperformedonradiologyreportsfromthepast10years(10/2004to10/2014)toidentify lesionsinvolvingthefibula.Inthecaseswherethetumorswereresectedthepathologicdiagnosisisobtainedfromtheelectronic medicalrecord. Tumorsofthefibulawillbepresentedincasebasedformatwithimagingfindingsandpathologiccorrelationwherepossible.Emphasis willbeplacedontechniquestonarrowthedifferentialdiagnosisbasedonradiography,MRIandclinicalparameters. 199 200 ePoster #27 WORKSTATIONBASEDCTRECONSTRUCTIONFORTHEDETECTIONOFVERTEBRALBODYCOMPRESSIONFRACTURES:WHATARE WEMISSING? KevinPreston;JosephBestic;HilliaryGarner;JeffreyPeterson;DanielWessell MayoClinicFlorida (Presentedby:KevinPreston) Introduction:Atourinstitution,PACSdisplayofchest,abdomenandpelvicCTexamsaretypicallyintheaxialplaneonly.Reformatting software(Aquarius,TeraRecon,Inc.,FosterCity,CA)isavailableattheworkstationforreconstructioninthedesiredplane,butmust belaunchedbythephysician.Vertebralbodycompressionfractures,especiallymildcompressionfractures,arenotoriouslydifficult, ifnotimpossible,todetectonaxialimagesalone.Ourinitialhypothesisisthatsimpleforgetfulnessorthecumbersomenatureof physician launched workstation reformats may result in failure to analyze the images in multiple planes, and thus compression fracturesmaybeoverlooked. MaterialsandMethods:Overa1monthperiod,the0.6mmaxialimagesof580consecutivechest,abdomen,andpelvicCTswere loaded into our workstationbased reformatting software and the images were reconstructed in the sagittal plane. Studies with multiplanarreconstructionsalreadyprovidedonPACSwereexcludedfromanalysis.Thesagittalplaneimageswerethenreviewedfor the presence of vertebral body compression fractures. All fractures were classified as acute, chronic, or age indeterminate as determinedbyreviewofpriorimagingstudiesandavailableclinicalrecords.CTreportswerereviewedinordertodetermineifthe fracturewas,orwasnot,describedintheoriginalradiologyreport. Results:62ofthe580(10.7%)CTexamscontainedatleast1vertebralbodycompressionfracture.45ofthe62(72.6%)compression fracturesweredeterminedtobechronicinnature,establishedbythepresenceofstablecompressiondeformityonapriorimaging studyoradocumentedcompressionfractureinthemedicalrecord.Ofthese,27of45(60%)werenotreportedand18of45(40%) were noted in the original radiology report. 17 of the 62 (27.4%) compression fractures were determined to be acute or age indeterminate,establishedbyeitheroverallCTappearance,intervalcompressiondeformity/heightlosswhencomparedtoaprior imagingstudy,and/orlackofdocumentedfractureinthemedicalrecord.Ofthese,10of17(58.8%)werenotreportedand7of17 (41.2%)werenotedintheoriginalradiologyreport. Conclusions:Onemayarguetheclinicalsignificanceofchronicendplatecompressionfracturesandtheneedfordocumentationin the radiology CT report. However, appropriate review of the study in multiple planes and documentation of acute compression fracturesiscrucialtoreducepatientmorbidityandpreventpotentialcomplications.Ifphysicianlaunchedreformatsarenotregularly performedasamatterofforgetfulnessorinconvenience,compressionfracturesmaybeoverlooked.Additionalanalysisofthenumber of overlookedcompression fractures following aperiodin which standard sagittal reformats are routinelyprovided on PACS may revealimproveddetectionrates. 201 ePoster #28 MRICHARACTERISTICSOFINTRANEURALSYNOVIALSARCOMA UsamaSalem;BehrangAmini;JeanneM.Meis TheUniversityofTexasM.D.AndersonCancerCenter (Presentedby:UsamaSalem) Purpose:Toreviewtheimagingappearanceofintraneuralsynovialsarcomaandraiseawarenessofthisentityinthedifferential diagnosisofamassarisingfromperipheralnerve.Background:Synovialsarcomarepresents510%ofsofttissuesarcomasandmost commonlyoccursintheextremitiesnearjoints.Intraneuralpresentationisrareandcanmimicmorecommonprimaryperipheral nervesheathtumorsonimagingandmalignantperipheralnervesheathtumorsonhistopathologicalexamination. MaterialsandMethods:Wereviewedourpathologydatabaseforcasesofsynovialsarcomaofthenerve.Caseswerereviewedbya sarcomapathologistforconfirmationofthediagnosis.TheMRimagingfeaturesof6caseswithpathologicalcorrelationarepresented. ResultsandConclusion:Intraneuralsynovialsarcomaisararecauseofamassarisingfromaperipheralnerveandmaybeconsidered inthisdifferentialconsiderationwhenfacedwithimagingfeaturesatypicalforaprimaryperipheralnervesheathtumor. 202 ePoster #29 REVERSETOTALSHOULDERARTHROPLASTY:RADIOLOGICIMAGINGANDEVALUATION SailajaYadavalli;ErgentZhiva;SunitVekaria BeaumontHealthSystem (Presentedby:SailajaYadavalli) Thenumberofreversetotalshoulderarthroplastiesperformedhasincreasedrapidlyinthelastdecadeandithasbecomeoneofthe commonlyseenprosthesesintheshoulder.Themostcommonindicationforreversetotalshoulderarthroplasty(RTSA)isinpatients withcompletetearsoftherotatorcufftendonswhoareunabletolifttheirarmsabovethehorizontal,aphenomenonknownas pseudoparalysis.Anunopposeddeltoidmusclecausessuperiormigrationofthehumeralheadanddisplacementofthecenterof motion. As a result patients have pain and significant compromise in range of motion. RTSA moves the center of rotation of the glenohumeraljointtoallowforimprovedrangeofmotioninpatientswithanintactdeltoidmuscle.However,noprosthesisisperfect andRTSAisalsoassociatedwithmultiplecomplications. Possible complications of RTSA include periprosthetic osteolysis, aseptic loosening, infection, hardware fracture, periprosthetic fracture,dislocation,malalignmentofthecomponents,postoperativehemorrhageandhematomasanderosionofthescapula.With suchawidevarietyofpossibilitiesforfailure,radiologicevaluationplaysanimportantroleinassessingthecauseofshoulderpainwith RTSA.Althoughradiographyistheprimarymodalityforinitialradiologicevaluation,otherimagingmodalitiessuchasCT,ultrasound and occasionally MRI also play a role in identifying the cause of prosthesis failure. Hence, it is important for the radiologist to understandthedesignoftheRTSAprosthesis,withrespecttohowthecomponentsfunctiontogether,theirproperplacementand causesoffailure. Thepresentationwilldiscussnormalradiographicappearanceofreversetotalshoulderprosthesisandpossiblecomplicationswith casesasexamples. LearningObjectives:1.Understandingthedesignofareversetotalshoulderprosthesisanditsnormalradiographicappearance.2. RecognizingradiologicfindingsrelatedtothemostfrequentcomplicationsofRTSA.3.Understandingthevalueofimagingmodalities otherthanradiographyintheevaluationofashoulderwithRTSA. 203 ePoster #30 IMAGINGSPECTRUMOFPECTORALISTEARS:PREOPERATIVEANDPOSTOPERATIVEMRIFINDINGS ShefaliKothary;GabrielleKonin;DarrylSneag HospitalforSpecialSurgery (Presentedby:ShefaliKothary) Pectoralis major tears are uncommon injuries that most frequently occur in high performance athletes and weightlifters but are becomingincreasinglymoreprevalentbecauseofhighintensitytraining.Thediagnosisofapectoralisinjuryisoftenconspicuouson clinicalexam.However,intheacutesetting,pain,decreasedrangeofmotion,edema,andhemorrhagemayprohibitcomprehensive assessmentbyphysicalexamination.Pectoralisminortearsareevenrarer,withonlyafewreportedcasesintheliteratureandare alsoseenalmostexclusivelyinathletes. Magneticresonanceimaging(MRI)evaluationisessentialindeterminingthepreciselocationandextentofpectoralisinjury,asearly andaccuratediagnosisofpectoralistearsdeterminestheappropriatemanagement.Promptimagingdiagnosisisessential,asdelayin treatmentcanresultinsignificantfunctionalmorbidity. Thispresentationwillincludeareviewofnormalanatomyusingillustrationsandimaging.Acasebasedapproachwillbeusedto exhibittheimagingspectrumofpectoralisinjuries,includingtearsofboththepectoralismajorandminor,withexamplesofcommon causes,suchasweightliftingandfootballinjuries,aswellasatypicalcausesnotpreviouslydescribedintheliterature,suchasskiing injuries.Theeffectiveimagingapproachforevaluatingpectoralismuscletearswillbereviewedwithdelineationoftheclassification oftears.Reviewoftreatmentoptions,includingbothconservativeandsurgicalmanagement,willbediscussed.Wewillhighlightthe postoperativeappearancefollowingpectoralisrepair,includingMRIexamplesofbothnormalandreinjuredtendons. 204 ePoster #31 DIAGNOSTICACCURACYOFSHOULDERMRIINCHARACTERIZINGBICEPSTENDONPATHOLOGYUTILIZINGSTANDARDIMAGING PLANESVERSUSADOUBLEOBLIQUET2WEIGHTEDFATSUPPRESSEDSEQUENCE ScottSheehan;HumbertoRosas;JasonStephenson UniversityofWisconsin (Presentedby:ScottSheehan) Objective: To retrospectively compare the diagnostic accuracy of a double oblique T2 weighted fat suppressed MR sequence to conventionalMRsequencesinthedetectionandcharacterizationofproximallongheadbicepstendonpathology. Materialsandmethods:ThisretrospectiveHIPAAcompliantstudywasperformedwithawaiverofinformedconsentfromtheIRB.A doubleobliqueT2weightedsequenceorientedperpendiculartothelongaxisoftheintraarticularportionofthelongheadofthe bicepstendonwasaddedtoaroutineshoulderMRprotocolin100patients(57males,meanage51yrs;43females,meanage53yrs) whosubsequentlyunderwentsurgicalintervention.Twofellowshiptrainedmusculoskeletalradiologists(8and5yearsofexperience) independentlyusedtheroutineMRsequencesduringthefirstreviewandthedoubleobliqueT2weightedsequenceduringthesecond reviewtodeterminethepresenceofbicepspathology.Thelongheadbicepstendonwascategorizedaseithernormal,tendinotic, partiallytorn,orruptured,andtheabsenceorpresenceofsubluxationwasrecorded.Tendinosiswasdefinedasafocalincreasein caliberwithoutevidenceofdisruptionofthesurfaceofthetendon.Partialtearsweredefinedbyeitheradiminishedcalibercentrally withinanareaoftendinosisresultinginanhourglassappearanceordisruptionofthesurfaceevidencedbyincreasedsignalintensity contactingtheperipheryofthetendon.Fullthicknesstearsweredefinedasdiscontinuityofthetendon.Byusingsurgicalfindingsas thestandardreference,thesensitivity,specificity,andaccuracyofbothimagingmethodswerecalculated,andsignificancetested usingtheMcnemarandStuartMaxwelltests.InterobservervariabilitywascalculatedusingtheCohen'skappastatistic,presentedas percentagreement. Results:Nostatisticallysignificantdifferencewasseenindiagnosticperformancebetweenthestandard(STD)sequencesanddouble oblique(DBL)sequencesforcharacterizingbicepstendinosisortearing(p=0.29),orsubluxation(p=0.37).Thesensitivity,specificity, andaccuracyofthestandardsequenceswere23%,87%,80%fortendinosis;88%,89%,89%forpartialtears;and93%,98%,98%for fullthicknesstearsrespectively.Thecalculatedsensitivity,specificity,andaccuracyofthedoubleobliquesequencewere32%,83%, 77%fortendinosis;78%,85%,83%forpartialtears;and93%,99%,99%forfullthicknesstearsrespectively.Interobserveragreement forratingtendonpathologywashigher(78%agreement,k=0.67)withtheSTDsequencesthanforDBL(60%agreement,k=0.42),but agreementondetectionofsubluxationwassimilarbetweenSTDandDBLrespectively(88%agreement,k=0.687;90%agreement, k=0.72). Conclusion: The sole use of the double oblique imaging sequence forthe evaluation of the long head biceps tendon providesno significantdifferenceinperformancerelativetothestandardsequencesforthediagnosisoftendinosis,partialtearing,fullthickness tears,orbicepstendonsubluxation,thoughmaydemonstratehigherinterobservervariabilityinthediagnosisoftendinosisortearing. Bothimagingsequencesetsallowforsensitive,specific,andaccuratecharacterizationofpartialtearing,fullthicknesstearing,and subluxationrelativetothesurgicalreferencestandard. 205 ePoster #32 INFERIORSUBSCAPULARISMUSCLESTRAIN–ANUNUSUALFINDINGINOVERHEADTHROWINGATHLETESWITHPOSTERIOR SHOULDERPAIN EricTarkowski;KevinBlount;StephenGryzlo;ImranOmar NorthwesternUniversityFeinbergSchoolofMedicine (Presentedby:EricTarkowski,MD) Background:Posteriorshoulderpainisacommonsymptominoverheadthrowingathletesduetotheextremestressesplacedonthe shoulder withabductionand external rotation in the late cockingphase and with early acceleration. The commonly encountered etiologiesofthispresentationincludeinternalimpingement(aspectrumoffindingsthatincludessupraspinatusandinfraspinatus tendontears,posteriorlabralfraying,andposteriorlateralhumeralheadedema),posteriorglenoidlabraltears,andposteriormuscle strains.WepresentthreecasesofposteriorshoulderpaininprofessionalbaseballpitcherswithMRimagingfindingsofinferiorbundle subscapularismyotendinousjunctionmuscleedema,suggestinginadditionaletiologyforsuchsymptomsinbaseballpitchers. Materials and Methods: Three professional baseball pitchers, seen between 2006 and 2014, presented to the team orthopedic surgeon with similar symptoms of posterior shoulder pain following throwing. MR imaging of their symptomatic shoulder was performedwithin5daysoftheirinjury.OneofthreepatientsunderwentevaluationwithMRshoulderarthrographywhiletheother tworeceivedroutineMRshoulderimaging.Thestudieswereeachinterpretedbyamusculoskeletalfellowshiptrainedradiologistat thetimeofexamcompletion.Theimagingfeaturesofeachstudywerethenlaterreviewedandcomparedwithoneanother,oncea patternwasidentifiedwithinthissetofpatients. Findings:Eachofthethreeathleteswasshowntohavemuscleedemawithintheinferiorbundleofthesubscapularismuscleatthe myotendinousjunction,consistentwithmusclestrain.Softtissueedemaextendedintotheaxillaandalongtheinferiorglenohumeral ligament.In1ofthe3patients,noadditionalfindingswereseentoexplaintheetiologyofthepatient’spain.Inasecondpatient,there was only an additional finding of a new small, partial thickness supraspinatus tendon tear involving less that 50% of the tendon thickness.Inthethirdpatient,therewasaposteriorlabraldetachment.However,nosignificantglenoidarticularcartilagelossor marrowedemawasseen.Theathletesweretreatedconservativelywithrest,andtheirsymptomsimprovedwithinseveralweeks. Conclusion: We have found three professional baseball pitchers presenting with posterior shoulder pain while throwing, who unexpectedlyhadsubscapularismyotendinousjunctionmusclestrains.Theprecisemechanismofsubscapularisinjurywasnotentirely clearinthesepatients.Additionally,thecauseforposteriorpaininthiscohortisuncertain.However,giventheproximityofthisinjury totheinferiorglenohumeralligament,itcouldberelatedtotransienttractionoftheaxillarynerveoritsfibers.Whileuncommon,the injurydoesappearassociatedwiththemechanismofoverheadthrowingandshouldbethoughtofinthedifferentialdiagnosisfor othercausesofposteriorshoulderpaininprofessionalthrowingathletes. 206 ePoster #33 MRIMAGINGOFATHLETICPUBALGIA:NORMALANATOMY,COMMONFINDINGSANDPITFALLS AbhijitDatir;BinduAvutu;JadChamieh;TarekNHanna;DouglasDRobertson;NabileSafdar EmoryUniversityHospital (Presentedby:AbhijitDatir) Purpose:Thepurposeofthisexhibitisto:1)Understandtherelevantnormalanatomyofthepelviswithregardstoathleticpubalgia onMRI,2)DepictthespectrumofMRIfindingsinathleticpubalgia,and3)Discusscommonimagingpitfallsthatmayleadtoerroneous diagnosisofathleticpubalgiainaspecificsubsetofathletes. Materials and Methods: We performed a retrospective database search of all collegiate and professional football players who underwent MRI of the pelvis with the athletic pubalgia protocol at our institution from 20102014. The MRI examinations were reviewedandfindingsseeninathleticpubalgiawereevaluated.Theseincluded:1)osteitispubis,2)thesecondarycleftsign,3)rectus abdominis tendinosis, tear or avulsion injury, 4) adductor longus tendinosis, tear or avulsion injury, and 5) aponeurotic injury or disruption. These findings were correlated withclinical examination, treatment and followup to confirm the diagnosis of athletic pubalgia.AdditionalfindingsonMRIofthepelviswerealsonotedthatmaypresentclinicallyasathleticpubalgia,suchasinguinal hernia,hipjointchondralinjury,labrocartilaginoustear,avulsioninjuryoftheanteriorinferioriliacspine,iliopsoasbursitis,andhip jointosteoarthritis. Results:ThenormalanatomyofpelvicMRIrelevanttoathleticpubalgiawillbereviewed.Wewillpresentnormalpubicsymphysis anatomyincludingthefibrocartilaginousdisk,primarycleftandassociatedligaments.Asuccinctapproachtotheanatomyofrectus abdominis,adductorlongus,andcommonaponeurosiswillbeshown.Typicalfindingsseeninathleticpubalgiaingeneral,andthose specificallyrelatingtocollegiateandprofessionalfootballplayerswillbediscussed.Also,imagingfindingsofentitiesthatwereclinically misdiagnosedasathleticpubalgiawillbeincluded. Conclusion:Athleticpubalgiaisacommonclinicaldiagnosisincollegiateandprofessionalfootballplayers.Athoroughunderstanding ofthenormalanatomywithappropriateprotocolremainsessentialforMRIevaluation.Anindepthknowledgeoftypicalfindingsas wellcommonpitfallsseeninathleticpubalgiawouldassistintheearlydiagnosisofthiscondition,potentiallypreventingfurtherinjury orlossofplayingtimeinthissubsetofathletes. 207 ePoster #34 COMPLICATIONSOFHIPARTHROSCOPY JuliaCrim UniversityofMissouri (Presentedby:JuliaCrim) Hip arthroscopy has become a common procedure. It is technically demanding. Complications include: incomplete/incorrectly positioned resection of a cam lesion, heterotopic ossification, cartilage damage, suture displacement, rapidly progressive osteoarthritis,jointinstability,psoasatrophy,insufficiencyfractureandinfection. Thisposterisapictorialessayshowingnormalandabnormalpostoperativeappearanceofthehiponimagingstudiesinpatientswith persistentornewpainfollowinghiparthroscopy. 208 ePoster #35 MRIOFPROXIMALFEMURMICROSTRUCTUREASNOVELBIOMARKERSOFSKELETALFRAGILITYANDFRACTURERISK KevinChu;RonaldAdler;GregoryChang NewYorkUniversityLangoneMedicalCenter (Presentedby:KevinChu) Introduction:Becausethemajorityofsubjectswithfragilityfracturesdonothavelowbonemineraldensity(BMD),thereisacritical needto identify other imagingbiomarkers of skeletalfragility andfracture risk. The goal of this study was todetermine whether magneticresonanceimaging(MRI)biomarkersofproximalfemurmicrostructuredifferinsubjectswithfragilityfracturescompared tocontrols. Methods:Thisprospectivestudyhadinstitutionalreviewboardapprovalandwritteninformedconsentwasobtainedfromallsubjects. Werecruited34postmenopausalwomen,18withfragilityfractures(meanage=58.8±8.8years,meanBMI=21.2±2.1kg/m2)and 16withoutfracture(meanage=60.1±9.5years,meanBMI=22.7±2.7kg/m2).Allsubjectswerescannedby:1)dualenergyxray absorptiometry(DXA)toassessfemoralneckandtotalhipbonemineraldensityand2)highresolution3TMRIusinga3DFLASH sequence(0.234mmx0.234mmx1.5mm)anda26elementreceivecoilsetuptoassessfemoralneckbonevolumefraction(BV/TV), corticalthickness(C.Th),andtrabecularthickness(Tb.Th). Results:Infracturecases/controls,meanfemoralneckBMDTscore,totalhipBMDTscore,BV/TV,C.Th,andTb.Th.were:2.3±0.4/ 2.1±0.6;1.5±0.9/1.7±0.7;0.60/0.54;1.76mm/1.81mm;0.56mm/0.59mm.OnlydifferencesinTb.Th.werestatisticallysignificant (p=0.023,allothersp>0.12). Conclusion:FemoralnecktrabecularthicknessasassessedbyhighresolutionMRImayhavevalueasanovelbiomarkerofskeletal fragilitybeyondtraditionallyusedbiomarkers(BMD,bonevolumefraction,femoralneckcorticalthickness).Furthervalidationwith largercohortsisnecessary. 209 ePoster #36 TRAUMATICSACRALFRACTURES:THREEIMPORTANTFRACTURECATEGORIES PushpenderGupta;ScottWuertzer;LeonLenchik WakeForestSchoolofMedicine (Presentedby:PushpenderGupta) Backgroundinformation:Thesacrumplaysakeyroleinmaintainingpelvicringstability.Sacralfracturesareoftenaresultofhigh energytrauma,occurringinapproximately45%ofpatientswithpelvicinjuries.Traumaticsacralfracturescanbebroadlycharacterized intothreecategories:1)sacralfracturesassociatedwithotherpelvicringinjuries,2)isolatedsacralfractures,and3)sacralfractures associatedwithspinopelvicdissociation.Mostcommonly,sacralfracturesareassociatedwithotherpelvicringfractures.Thesemay bestable,partiallystable,orunstableandmayrequireoperativefixation.Lessthan5%ofsacralfracturesareisolatedinjuries.These areusuallystableandtreatednonoperatively.Quiterarearesacralfracturesthatresultinspondylopelvicdissociation(SPD).SPD consistsofmechanicaldissociationofthespineandlowerextremitywhichisalwaysunstable,hasahighincidenceofneurologicinjury, andrequiresoperativefixation.Thepurposeoftheexhibitistofamiliarizetheradiologistwithimagingfindingsofthesetraumatic sacralfracturecategories. Teachingpoints:1.Sacralfracturescommonlyresultfromhighenergytraumaandareassociatedwithhighincidenceofneurological injuries.2.Ararebutimportantsacralfracturepattern,knownasspinopelvicdissociation,mustbedifferentiatedfromotherfracture patterns.3.Thediagnosisofsacralfracturesisoftendelayedduetocomplexanatomy,overlappingbowelobscuringfinebonydetail onradiographs,andassociatedpolytrauma. Keyimagingtechniques:Standardpelvicradiographsrevealonly30%ofallsacralfractures.CTisessentialforaccuratediagnosisand characterizationofdifferentsacralfracturepatterns.MRImayhelpintheevaluationofpatientswithneurologicaldeficits. Conclusion: Accurate and timely diagnosis of sacral fractures is important for optimal patient management and prevention of progressivepainfuldeformitiesand/orneurologicaldysfunction. 210 ePoster #37 3DMRVS.3DCTOSSEOUSRECONSTRUCTIONSOFTHEHIPUSINGAGRADIENTECHOBASED2POINTDIXONRECONSTRUCTION:A COMPARISONSTUDY AvnerYemin;LuisS.Beltran;JonathanVigdorchik;MichaelBloom;JamesBabb;SoteriosGyftopoulos NYULangoneMedicalCenter (Presentedby:AvnerYemin) Todetermineif3DMRreconstructionsofthehipcanbeusedtoaccuratelydemonstratefemoralandacetabularmorphologyinthe settingoffemoroacetabularimpingementandhipdysplasia. Weperformedaretrospectivereviewof14consecutivepatientswhounderwentbothCTandMRIofthesamehipatourinstitution. Each MR examination included an axial Dixon 3D sequence, which was used to produce 3D reconstructions of the hip. Each CT examination included 3D reconstructions of the same hip. Two fellowship trained musculoskeletal radiologists (4 and 1 years of experience)reviewedthe3DMRreconstructionsofeachhipinconsensusandblindtothepatient’sclinicalhistoryfirst,followedbya review of the 3DCT reconstructions two weeks later, also conducted blindly. For each study, the femoral 3D reconstruction was evaluatedforthepresenceofacamlesion,definedasreducedoffsetatthefemoralheadneckjunction,anditsextent,definedas located in the anterosuperior (AS) and/or anteroinferior (AI) quadrants of the femoral headneck junction. Each acetabular 3D reconstructionwasreviewedandusedtomeasureacetabularsurfacearea(SA),acetabularheight,andacetabularwidth.Thefindings on the 3DCT reconstructions were considered the reference standard. Statistical analysis included McNemar tests to compare modalitiesintermsofthepercentageofpositivecallsforeachattribute,thespecificity/sensitivityof3DMRIforthedetectionofeach attributerelativeto3DCT,concordancecorrelation(CC)tomeasureliteralagreementbetweentheMRandCTmeasuresandpaired samplettesttoassessthemean/standarddeviation(SD)ofthepercentagedifferencebetween3DMRIand3DCTintermsofeach measure. Of the 14 patients, there were 9 females/5 males with mean age 32 (range 1542). Four patients had a clinical diagnosis of femoroacetabularimpingement,whiletheother10hadadiagnosisofhipdysplasiabasedonclinicalandradiographicfindings. Therewasnostatisticallysignificantdifferencebetweenthetwomodalitiesregardingthepresenceofanyofthefemoralattributes (%agreement):campresent100%(p=1),caminAS78.6%(p=1),andcaminAI92.9%(p=1).The3DMRimageswerehighlysensitive andspecificindetectionofeachfemoralattributerelativeto3DCT(Sp%/Sn%):campresent100%/100%,caminAS75%/83.3%,and caminAI100%/90%. There was substantial agreement between the acetabular measurements on 3DMR and 3DCT (CC values): acetabular SA 0.86, acetabularheight0.8,andacetabularwidth0.83.TherewasnostatisticallysignificantdifferenceinmeanandSDofthepercentage differencebetween3DMRand3DCTforeachacetabularmeasurement:acetabularSA3.1±5.9%(p=0.45),acetabularheight1.4±3.8% (p=0.237),andacetabularwidth1.8±3.2%(p=0.071). 3DMRosseousmodelsofthehipcanbeproducedusinga3DDixonsequencetoaccuratelyassessfemoralandacetabularmorphology inthesettingoffemoroacetabularimpingementandhipdysplasia. 211 ePoster #38 CONCEPTSOFOPERATIVETREATMENTINSCAPHOLUNATEINSTABILITY:ANIMAGINGPERSPECTIVE KimiaKKani;HyojeongMulcahy;FelixS.Chew AdvancedImagingCenter (Presentedby:KimiaKKani,MD) Purpose:Scapholunate(SL)instabilityisthemostcommoncauseofcarpalinstability.Thepurposeofthisexhibitistoreviewthe framework of the decision making process for treatment of SL instability, value of imaging in the preoperative assessment of SL instability,andexpectedimagingfindingsandpotentialcomplicationsonpostoperativeimaging. Teachingpoints/Educationalgoals:1.UnderstandingthestagingofSLinstabilityasausefulframeworkfortreatmentalgorithms.2. Recognize the different treatment options in reducible SL instability. 3. Identify the different treatment options in irreducible SL instability.4.RecognizethepertinentpreoperativeimagingfindingsespeciallyonconventionalradiographyandMRimaging(including MRarthrography).5.Identifythespectrumofnormalpostoperativefindingsespeciallyonconventionalradiography.6.Recognize complicationsonpostoperativeimaging.Keyissues:ImagingplaysacrucialroleinpreoperativestagingofSLinstabilities.Reducible queSLinstabilitymaybetreatedwitharthroscopicdebridement/+temporaryfixation,SLligamentrepair,SLligamentreconstruction ortheRASL(reductionandassociationofthescaphoidandlunate)procedure.Radialstyloidectomy,limited,fourcornerandtotal wrist arthrodesis or wrist arthroplasty are treatment options for irreducible SL instability. Follow up imaging is necessary for monitoringofpotentialpostoperativecomplications. Conclusion:DifferentsurgicalproceduresaretargetedtotreatvariousstagesofSLinstability.Familiaritywiththedifferentsurgical optionsisaprerequisiteforcorrectinterpretationofpostoperativeimages 212 ePoster #39 MRIMAGINGOFSOFTTISSUEINJURIESOFTHEFINGERS KimiaKKani;HyojeongMulcahy;FelixS.Chew AdvancedImagingCenter (Presentedby:KimiaKKani,MD) Fingerinjuriesarecommonlyencounteredinsportsandworkrelatedtraumas.Thepurposeofthisexhibitistoreviewthepertinent anatomyanddiscusstheMRimagingfindingsofcommonlyencounteredsofttissuefingerinjuries. Teachingpoints/educationalgoals:1.DiscussandindividualizetheanatomicstructuresoffingersonnormalMRimages.2.Discuss theappropriateMRIprotocolsindifferenttraumaticsettings3.RecognizetheMRimagingspectrumofcommonlyencounteredacute andchronicsofttissueinjuriesoffingers.4.Recognizetheanatomicabnormalitiesunderlyingcommonlyencounteredposttraumatic fingerdeformitiesKeyissues:1.NormalMRIanatomyofflexorandextensortendons,extensorhood/extensorapparatus,annular pulleys,volarplate,andcollateralligaments.2.AppropriateMRIprotocolsindifferenttraumaticsettings3.MRIimagingspectrumof acutetochronic,ulnarandradialcollateralligamentinjuries(includingStenerlesions)4.MRimagingspectrumofvolarplateinjuries 5. The anatomic zones and MR imaging appearance of flexor and extensor tendon injuries 6. Anatomic abnormalities underlying commonlyencounteredposttraumaticfingerdeformities Conclusion:MRimagingisinvaluableforevaluationofsofttissuefingerinjuries.CorrectinterpretationofposttraumaticfingerMR imagesdependsonstepwiseandorganizedevaluationoftheligamentsandtendonsatthelevelofinjury.Awarenessofthemechanism andacuityofinjury,alongwithexaminationoftheinjuredfingermayimproveaccuracyofimageinterpretation. 213 ePoster #40 COSTOCHONDRALINJURIES:HOWNOTTOMISSIT! ManickamKumaravel;NicholasBeckmann;SusannaSpence;UsmanAnwer UniversityofTexas (Presentedby:ManickamKumaravel) Purpose/Aim:Exhibitaimsto1.Discussindetailthecostochondral(CC)anatomy2.Discussvariousimagingmethodstoidentifythe costochondralcartilageusingradiographs,ultrasound,CTandMRI3.Elucidatevariouscasesofcostochondralinjuriesincludingnon displaced, displaced fractures, associated injuries and manifestations. 4. Review management and postoperative imaging of the varioustypesofcostochondralinjuries.Contentorganization:1.Grossanatomyimagesofcostochondralcartilage–withmultiple dissectedspecimens.2.Detailedradiography,CT,ultrasoundanatomyandMRIanatomyofthecostochondralcartilage.3.Illustrated plainradiography,CTandMRIexamplesofvariouspathology–includingnondisplaced,displacedfractures,associatedinjuriesand manifestationsconditionsofthecostochondralinjuries.4.Comprehensivetreatmentmethodsforcostochondralpathology. Educationalobjectives:Onstudyingtheexhibitthereviewerwillbeableto1.Understandtheanatomyofthecostochondralcartilage indetail2.Recommendoptimalimagingstudiestoevaluatethecostochondralcartilage3.Haveadetailedknowledgeofthevarious pathologies involving the costochondral cartilage and treatment protocols. 4. Be familiar with post³opera´ve appearance of the costochondralinjuries. 214 ePoster #41 SONOGRAPHYOFORTHOPEDICHARDWARECOMPLICATIONS JonellePetscavageThomas;CristyGustas PennStateMiltonS.HersheyMedicalCenter (Presentedby:JonellePetscavageThomas) Backgroundinformation/Purpose:Softtissuecomplicationsoforthopedichardwareareoftendifficulttoevaluatewithcomputed tomographyandmagneticresonanceimagingduetometalrelatedartifacts.Ultrasoundisnotlimitedbytheseartifacts,demonstrates the hardware, and assists in assessing adjacent soft tissues and neurovascular structures. Additionally, dynamic ultrasound can demonstrate impingementand snapping syndromes relatedto hardware. Educational goals/teachingpoints • Understandnormal sonographic appearance of orthopedic hardware • Learn dynamic maneuvers used to diagnose hardware related impingement syndromes • Recognize sonographic appearance of complications related to hardware • Illustrate ultrasound guided therapeutic procedurestotreathardwarerelatedcomplications Results: This exhibit demonstrates the following ultrasound cases of soft tissue complications of orthopedic hardware: pseudoaneurysm,bursitis,infection,screwfracture,muscleimpingementwithatrophy,nerveimpingement,adversereactiontometal debris(ARMD),andtendonimpingementandsnapping. Conclusion: Ultrasound is useful to evaluate orthopedichardwarebecause it is not limited by metal artifactsand allows dynamic examination.Ultrasoundguided therapeutic aspiration and/or injections can also be performed incases wherecomplications are detected. 215 ePoster #42 DEBUNKINGTHEMYTHSOFGOUT SayedAli;StephenLing TempleUniversityHospital (Presentedby:SayedAli) PURPOSE: A common myth is that gout and rheumatoid arthritis (RA) do not coexist, and are protective against each other. We determinedtheincidenceofcopresentgoutandrheumatoidarthritis,andassessedthedemographicandradiologicalfeaturesofthis unusualphenomenon. MATERIALSANDMETHODS:Aretrospectivechartreviewofpatientsseenatourinstitutionbetween1/1/2003and12/12/2013was performed,todeterminethepresenceofICD9codesforbothgoutandrheumatoidarthritis.Thesepatientswerethenevaluatedto determine whether they met the 2010 American College of Rheumatology (ACR) criteria for rheumatoid arthritis and the 1977 American Rheumatism Association (ARA) criteria for gout. Despite meeting the criteria for both entities, we only included those patientsthathadsynovialfluidaspirationconfirmingthepresenceofmonosodiumuratecrystals.PatientswithHepatitisC(HCV)or suspectedHepatitisCarthritiswerealsoexcluded.Radiographswerethenevaluatedforthepresenceofmarginalor“punchedout” erosions,cysticchange,jointspacenarrowing,ankylosis,deformity,softtissuechangesandosteopenia. RESULTS:Outof101patientswithICD9codesforRAandgout,12casesmet2010ACRcriteriaforRAaswellas1977ARAcriteriafor gout.All12wereAfricanAmericans.Ofthese12cases,4caseshaddemonstratedmonosodiumuratecrystalsinjointfluid,ortophus formationproventocontaincrystals.1patientwasexcludedforhavingadiagnosisofHCVwithsuspectedHCVassociatedarthritis. Ofthethreeremainingcases,twoweremales.Theaverageagewas59years.OnepatientwaspositiveforRheumatoidFactor(RF) andAnti–citrullinatedproteinantibodies(ACPA).AllpatientshadahighHDL(>100mg/dL)andlowLDL(<70mg/dL)intheabsence oflipidloweringagents.Ontheradiographs,twohadosteopeniaandcysticchange,andthreehaderosionsandjointspacenarrowing. Theerosionsweremoretypicalforrheumatoid,beingmoremarginaltypewithno“punchedout”erosions,andinvolvingtheproximal structures including the distal ulna, radiocarpal joint, carpometacarpal articulations. Two patients had erosions at the second metacarpophalangealjoint.Cysticchange,ulnardeviation,volarsubluxationattheMCP’sandosteopeniawerepresentintwocases. Alargesofttissuetophusdorsaltothemetacarpalswasseeninonepatient. CONCLUSION:InourmostlyAfricanAmericanpatientpopulation,allofthepatientswithcoexistingRAandgoutareAfricanAmerican. Themajorityofthesepatientshavetophi.TheytendtobeseronegativewithregardstoRFandACPA,andhaveanabnormallipid profile.Radiographically,theyaremostlikelytohavemarginaljointerosionsresemblingRA,butnotthe“punchedout”typeerosions oroverhangingedgestypicallyseeningout.Cysticerosions,subluxationsandperiarticularosteoporosisalsoresemblingRAareseen. TypicalosseouscharacteristicsofgoutthereforeappearstobedownplayedingoutcoexistingwithRA. 216 ePoster #43 NANOFRACTURES:ALLYOUWANTEDTOKNOW! ManickamKumaravel;NicholasBeckmann;SusannaSpence UniversityofTexas (Presentedby:ManickamKumaravel) Purpose / Aim: Exhibit aims to 1. Discuss in detail thevarious typesof cartilage injury.2.Discuss role ofMesenchymalStem cell Stimulation(MSS)incartilagetreatmentandrepair.3.Discussindetailthesurgicaltechniqueandpathophysiologyandimagingof technique of Nano fractures method of MSS. 4. Review imaging of Nano fractures with examples of postoperative imaging and complications.5.ComparetheMSStechniquesofMicrofracturesvs.Nanofracturesalongwithimagingexamplesofbothtechniques. Contentorganization:1.IllustrationoftechniquesofNanofractureswithcartoonsandintraoperativepicturesandvideo.2.Detailed imagingincludingCT,andMRIimagesofNanofractures,includingexamplesofnormalpostoperativeappearancesandcomplications. 3. Comparative MRI examples of Micro fractures and Nano fractures and their complications. 4. Comprehensive discussion of treatmentalgorithmofNanofractures. Educationalobjectives:Onstudyingtheexhibitthereviewerwillbeableto1.Understandthetypesofcartilageinjury.2.Understand the techniques of MSS – Nano fracture and micro fracture. 3. Have a detailed knowledge of the surgical techniques, imaging appearance of Nano fractures – including normal and abnormal MRI appearances and treatment algorithms. 4. Be familiar with comparativeimagingappearanceofNanoandmicrofractures. 217 ePoster #44 SECRETSOFTHEPERIOSTEUM:CLUESTOUNDERLYINGOSSEOUSANDMETABOLICDISEASES CynthiaBritton UniversityofPittsburghMedicalCenter (Presentedby:CynthiaBritton) Theperiosteumisanimportantcomponentofskeletalstructure.Composedofanouterfibrouslayerandinnerosteogeniclayer,it provides blood supply to the underlying bone, augments osteogenesis and serves as support for ligamentous and muscular attachments. Periosteal reaction is frequently a sign of focal underlying osseous disease, may be diffuse and associated with an accompanying knowndiseaseorsyndrome,occurasasideeffectofdrugtherapyormaybeanincidental/asymptomaticfinding. Therearerecognizedpatternsofnonaggressiveandaggressiveperiostealreactionwhichwillbedemonstratedinthisexhibit.This includesthin,solid,thickirregular(nonaggressive),laminated,haironend,sunburstandCodman'striangle(aggressive). Unfortunately,thepatternofperiostealreactionisnotalwaysspecificforaparticularentityandismorereflectiveoftheseverityor rapidityoftheinsulttotheperiosteum.Ingeneral,childrendemonstratemorestrikingperiostealreactionastheperiosteumismore looselyattachedtotheunderlyingbone,andaggressivepatternsaremorecloselyassociatedwithtumororsevereinfectioninboth adultsandchildren. Nonetheless,anapproachtothediagnosisandetiologyofperiostealreactionwillbepresentedwithregardtopattern,age,focal versusdiffuseandassociationwithdiseases,syndromesordruguse.Examplesoftheseentitiesincludingarthritis(psoriatic),metabolic (HPOAandthyroidacropachy),congenital(newborn),drugs(variconazole),tumors(osteosarcoma,Ewing'ssarcoma,osteoidosteoma, juxtacortical chondroma, ErdheimChester disease), infection and vascular insufficiency will be included in this exhibit with their correspondingperiostealreactionpatternsinanefforttohelpclarifytheconfusionwhichmayaccompanythediagnosisofperiostitis anditssignificance. 218 ePoster #45 PITFALLSINCERVICALSPINECTINTHETRAUMAPATIENT JoesphLivingston;JohnBoardman;AndrewWilmot;CarolL.Andrews UniversityofPittsburghMedicalCenter (Presentedby:JoesphLivingston,M.D.) PURPOSE:CervicalspineCTistheacceptedscreeningmodalityintheevaluationforcervicalspineinjuryintraumapatientsduetoits high sensitivity, speed of acquisition, and widespread availability. Technical factors, normal anatomic variants, and nontraumatic pathologies can mimic traumatic injury. In addition, given the focus on identifying traumatic injury, clinically relevant incidental findingsinthespineandsurroundingstructuresmaybeoverlookedorunderreported. MATERIALS AND METHODS: The following topics will be presented in a series of case presentations: 1. Review common pitfalls includingtechnicalfactors,agerelatedchanges,normalanatomicvariants,andcongenitalanomaliesincludingsuchtopicsasnon traumatic prevertebral soft tissue thickening, motion induced artifacts, vascular channels, etc. 2. Imaging clues to the correct diagnosiswillbeemphasized.3.Reviewmethodstoavoidmisinterpretationofpitfalls.4.Stresstheimportanceofclinicaldataand correlativeimagingwhenCTisinconclusive. CONCLUSION:Understandingandavoidingcommonpitfalls,recognizingnormalvariantsandusingsuggestedstrategiesforarriving atacorrectdiagnosiswillassureoptimalpatientcareandclinicaloutcome. 219 ePoster #46 BACKPAININCHILDRENANDYOUNGADULTS:BEYONDSPONDYLOLYSIS ShefaliKothary;DarrylSneag;DouglasMintz;YoshimiEndo HospitalforSpecialSurgery (Presentedby:ShefaliKothary,MD) Backpainisnotacommoncomplaintinchildrenandyoungadults,andmedicalattentionisoftennotsoughtout.However,inmany casestheetiologyisoftenduetosignificantunderlyingpathology.Frequentlypresentingasanonspecificsymptom,thedifferential diagnosisisbroadwithvariousalgorithmsforimagingworkup.Thepurposeofthisexhibitistoreviewtheclinicalfeatures,imaging evaluation,andspectrumofimagingfindingsofmusculoskeletalpathologycausinglowbackpaininchildren,aswellastreatmentsfor thesevariousentities. Atourinstitution,themostcommonindicationforimagingofthelumbarspineinthepediatric/youngadultpopulationistoassess for spondylolysis. Imaging features of spondylolysis, including completeness, laterality, and chronicity, have implications for managementandprognosis,andwillbediscussedindetail. Using a casebased, multimodality approach, we also describe the spectrum of other common and uncommon musculoskeletal conditionsleadingtolowbackpain,includingothertraumaticcauses,suchaspedicleandvertebralbodyfractures,anddischerniation; infectious causes, such as, discitis, osteomyelitis, and chronic recurrent multifocal osteomyelitis; inflammatory causes, such as ankylosingspondylitisandjuvenileidiopathicarthritis;neoplasticcauses,suchasosteoidosteoma,osteoblastoma,andleukemia;and otherconditions,suchassicklecelldisease,Scheuermann’sdisease,andLangerhanscellhistiocytosis.Eachentitywillbediscussed withdelineationoftheepidemiology,clinicalfeatures,pathophysiology,imagingfeatures,andtreatments.Knowledgeoftheimaging approachandcharacteristicimagingfindingsoftheseentitiescanassistinanaccuratediagnosisandpromptinitiationoftreatment. 220 221 ePoster #47 FACINGTHEFACTS:USINGPATTERNRECOGNITIONTOMAKEFACIALCTEASY SusannaC.Spence UniversityofTexas (Presentedby:SusannaC.Spence) INTRODUCTION:FacialCTisanareathatmanyradiologistsfindcomplex.Describingtheindividualbonesfracturediseasy,butdrawing thoseindividualfracturesintoacohesivepatternforeffectivecommunicationwiththereferringcliniciansrequiresadeeperfamiliarity withthosepatterns.Acommonimpression:“Complexfacialfracturesasdescribedabove.”Howdoweavoidthisinabilitytosimplify? Patternrecognitionisakeycomponentofthisprocess:IseepterygoidplatefracturesthereforeIlookforaLeFortpattern.Iseea zygomaticarchfracturewithoutapterygoidplatefracture,nowI’mlookingfortheZMC.Knowledgeofthesepatternsalsokeepsthe radiologistfrommissingkeyinjuries,becausetheyalreadyknowtheinjurySHOULDbethere. CONTENTOVERVIEW:OverviewofthemajortypesofinjurypatternsvisibleonfacialCT,fromLeFort,ZMCandNOE,toclassification oftemporalbonefractures.Softtissueinjuriestotheglobesandorbitswillalsobereviewed.Focusonpatternrecognition:Isee bilateraltemporalbonefractures,sowhere’sthecentralskullbasefracture?Wherearetheothercomponentsofthispattern?What doesthesurgeonneedfromme?Useof3Dimagesforproblemsolving,andforlearningthetypesofpatterns.Oncethepatternsare familiar,the3Dswillnolongerbenecessary,butthey’reagreatwaytogetthewholepictureforthosewhoarelessexperienced. SUMMARY:Facialfracturesareoftenfoundinpatientswithmultipleotherinjuries.HavingacomplexfacialCTbringyoutoagrinding haltwhenapatienthasmultipleotherinjuriesneedingtobeaddressedisaninefficientuseoftimeduringthat“goldenhour.”Learning thesesimpletechniqueswillallowtheradiologisttocoverallthekeypoints,classifyandmoveon. 222 ePoster #48 MAGNETICRESONANCEIMAGINGFINDINGSOFPERIPHERALNERVESINCHARCOTMARIETOOTH SangeetaChaudhary;JonellePetscavageThomas;StephanieABernard;EricAWalker PennStateHersheyMedicalCenter (Presentedby:SangeetaChaudhary) Purpose:CharcotMarieTooth(CMT)diseaseisthemostcommoninheritedneurologicaldisorderoflowermotorneurons.Known imaging findings include cavovarus alignment in the foot, hypertrophic nerve roots with an onion bulb appearance, and muscle denervation.Thereislittle,ifanypublishedliteraturedemonstratingthemagneticresonanceimaging(MRI)featuresoftheperipheral nervesinCMT.Thepurposeofthisstudywastodeterminetheimagingfeaturesoflowerextremityperipheralnervesandpatternsof muscledenervationinpatientswithCMT. Methods:AretrospectivereviewwasperformedofMRIexaminationsofthelowerextremityinpatientswithCMTandofanageand sexmatchedcontrolgroup.2fellowshiptrainedmusculoskeletalradiologistsindependentlyrecordedmaximumnervediameterand T1,T2/STIR,andpostgadoliniumsignalintensityoftheposteriortibialnerveinthetarsaltunnel.Changesofdenervationatrophyand edemawererecordedinthemusclesinnervatedbythenerve.Patientdemographicdata,otherpathologyontheMRI,andEMGreport (if available) were also recorded. Statistical analysis included calculation of mean nerve diameter with standard deviation, ttest comparisonofthemeanswithpvalueand95%confidenceinterval,andinterobserveragreement. Results:8CMTpatientshadatotalof8examsoftheankle(5male,3female)(agerange2058).8ageandsexmatchedcontrolankle werealsoevaluated.MeanfasciculardiameteroftheposteriortibialnerveintheCMTgroupwas6.88mm+/1.15mmcomparedto 3.69mm+/.95mminthecontrols,whichwasstatisticallysignificant(p<0.05,CI2.433.95).NervesignalintheCMTgroupwashypo toisointenseonbothT1andT2anddidnotdemonstratemarkedenhancement.Thiswassimilartothecontrolgroup.Therewas alsoastatisticallysignificantdifferenceinpresenceofmuscledenervationedemachanges(p<0.05)intheCMTgroupcomparedto controls.Interobserveragreementwas0.967. Conclusion: MRI findings of peripheral nerves in CMT include fusiform enlargement likely due to hypertrophic demyelination. However,signalcharacteristicsremainnormal,differentiatingthisentityfromLeprosy,viralneuritis,andotherdiseasethatresultin enlargednerveswithincreasedT2/STIRandpostgadoliniumsignalinthelowerextremities. 223 ePoster #49 SCHWANNOMATOSIS:REVIEWOFIMAGINGANDCLINICALFEATURESINARECENTLYRECOGNIZEDENTITY ShivaniAhlawat;AsadBaig;JaishriBlakeley;MichaelJacobs;LauraMFayad JohnsHopkinsUniversity (Presentedby:ShivaniAhlawat) Objectives:Thepurposeofthiseducationalexhibitisreviewtheclinicalandimagingmanifestationsofschwannomatosis.Background: Neurofibromatoses(NF),includingneurofibromatosistype1(NF1),neurofibromatosistype2(NF2)andschwannomatosis(SWN),are aheterogeneousgroupofgeneticsyndromeswithapredispositiontocentralandperipheral,neurogenictumors.SWNisadistinctNF entitywithmultipleschwannomasbutabsenceofbilateralcranialnerveVIIIinvolvementasseeninNF2.Theclinicalandgenetic diagnosticcriteriaforSWNareevolving.Discussion:TheexhibitwillreviewtheliteratureonSWNwithregardstogeneticandclinical diagnosticcriteria.TheworkupofpatientswithSWNisevolvingandincludeslocalizedandwholebodymagneticresonance(WB MRI)techniquesandwillbeillustratedinthisexhibit.EmergingMRItoolssuchasfunctionalimagingwithdiffusionweightedimaging (DWI)withapparentdiffusioncoefficient(ADC)mappingintheassessmentofSWNwillbediscussedandtheroleofmetabolicimaging with18FFDGPET/CTwillbereviewed. Conclusion:SWNisararebutclinicallydistinctsyndromewithintheNFfamilyofdiseases.Theradiologistshouldbefamiliarwiththe clinicalandimagingmanifestationsofschwannoamtosisastheyplayacriticalroleindiagnosisandmanagement. 224 ePoster #50 TRAUMATICNEUROMAS:COMMONMRIFEATURES ShivaniAhlawat;AllanJBelzberg;ElizabethMontgomery;LauraMFayad JohnsHopkinsUniversity (Presentedby:ShivaniAhlawat) OBJECTIVES:Thepurposeofthiseducationalexhibitistoreviewnoncontrastandcontrastenhancedmagneticresonanceimaging (MRI)featuresoftraumaticneuroma. BACKGROUND:Atraumaticneuromaisadisorganized,fibroneuralmassthatdevelopsasaresultofaninjuryandresultantfailed attemptatnerveregeneration.Traumaticneuromasaresevereinjuriesofthenervethatcanbeclassifiedintoendbulbneuromas (EBN)aftercompletedisruptionorneuromaincontinuity(NIC)afterpartialnervetransection. DISCUSSION:Becausetraumaticneuromaspresentasmasslikeenlargementofaperipheralnerve,thesepseudotumorscansimulate PNSTs. Traumatic neuromas demonstrate continuity with the parent nerve proximally, analogous to a “tail sign” associated with peripheralnervesheathtumors(PNSTs),indicatingtheirneurogenicorigin.However,EBNslackdistalcontinuitywiththeparentnerve, whileNICsarecontiguousbothproximallyanddistally.TheunderlyingpathophysiologyoftraumaticneuromasandtheresultantMRI appearanceofEBNsandNICswillbereviewed.Incontrast,theexpectedhistologicalarchitectureofPNSTssuchasneurofibromaand schwannoma, and the typical MRI appearance will also be reviewed. Role of contrast material administration as a distinguishing feature between neuromasand other neurogenic lesions will be critiqued. Differential diagnosis of traumaticneuromas including othernonneoplasticperipheralnervelesionswillalsobedescribed. CONCLUSION: Traumatic neuromas can mimic other neoplastic and nonneoplastic lesions associated with peripheral nerves. KnowledgeofcommonMRIfeaturesandantecedenthistoryoftraumaallowstheradiologisttosuggestthecorrectdiagnosisinthe appropriateclinicalsetting. 225 226
