Ultrasound of the knee

Ultrasound is emerging as a viable imaging modality in the diagnosis and assessment of the musculoskeletal system. Advantages of ultrasound include its easy availability and multiplanar capability, as well as economic advantages. Unlike magnetic resonance imaging, ultrasound demonstrates the fibrillar microanatomy of tendons, ligaments and muscles, enhancing its diagnostic capability. The ability to compress. dynamically assess structures and compare easily with the contralateral side is advantageous. The patient's exact point of clinical tenderness can be correlated with underlying anatomical structures and associated pathology. The main strength of knee ultrasound is the assessment of para-articular disease. The specific structures best suited for ultrasound assessment include tendons, muscles and ligaments, as well as periarticular soft tissue masses. Joint effusions, synovial thickening, bursal fluid collections, intra-articular loose bodies, ganglion cysts, ligament and tendons tears, tendonitis and occult fractures can be diagnosed. With experience, ultrasound is a time-efficient, economical imaging tool for assessment of the knee.

Vibration therapy in multiple sclerosis: a pilot study exploring its effects on tone, muscle force, sensation and functional performance

Objective: To examine the effectiveness of whole body vibration (WBV) on tone, muscle force, sensation and functional performance in people with multiple sclerosis.

Design: A randomized cross-over pilot study.

Setting: Revive MS Support Therapy Centre. Glasgow, UK.

Subjects: Sixteen people with multiple sclerosis were randomly allocated to one of two groups.

Intervention: Group 1 received four weeks of whole body vibration plus exercise three times per week, two weeks of no intervention and then four weeks of exercise alone three times per week. Group 2 were given the two treatment interventions in the reverse order to group 1.

Main measures: Ten-metre walk, Timed Up and Go Test, Modified Ashworth Scale, Multiple Sclerosis Spasticity Scale (MSSS-88), lower limb muscle force, Nottingham Sensory Assessment and Multiple Sclerosis Impact Scale (MSIS-29) were used before and after intervention.

Results: The exercise programme had positive effects on muscle force and well-being, but there was insufficient evidence that the addition of whole body vibration provided any further benefit. The Modified Ashworth Scale was generally unaffected by either intervention, although, for each group, results from the MSSS-88 showed whole body vibration and exercises reduced muscle spasms (P = 0.02). Although results for the 10-m walk and Timed Up and Go Test improved, this did not reach statistical significance (P = 0.56; P = 0.70, respectively). For most subjects sensation was unaffected by whole body vibration.

Conclusion: Exercise may be beneficial to those with multiple sclerosis, but there is limited evidence that the addition of whole body vibration provides any additional improvements. Further larger scale studies into the effects of whole body vibration in people with multiple sclerosis are essential.

CONSENSUS REPORT: Recognizing non-melanoma skin cancer, including actinic keratosis, as an occupational disease - A Call to Action

1. Non-melanoma skin cancer (NMSC) is by far the most common cancer diagnosed in westernized countries, and one of the few almost preventable cancers if detected and treated early as up to 90% of NMSC may be attributed to excessive exposure to ultraviolet radiation. 2. The incidence of NMSC is increasing: 2-3 million people are diagnosed worldwide annually, with an average yearly increase of 3-8% among white populations in Australia, Europe, the US and Canada over the last 30 years. 3. The link between solar ultraviolet (UV) radiation and certain forms of NMSC is clearly recognized. It is estimated that outdoor workers are exposed to an UV radiation dose 2-3 times higher than indoor workers, and there is a growing body of research linking UV radiation exposure in outdoor workers to NMSC: I. Occupationally UV-exposed workers are at least at a 43% higher risk of basal cell carcinoma (BCC) and almost doubled risk of squamous cell carcinoma (SCC) compared to the average population, with risk increasing with decreasing latitude. II. The risk for BCC, SCC and actinic keratosis (AK) among workers who have worked outdoors for more than 5 years is 3-fold higher than the risk among those with no years of working outdoors. 4. Primary prevention, early detection, treatment and regular follow-up of skin cancer (NMSC and melanoma) are shown to be beneficial from a health economic perspective. 5. Action is needed at international, European and national level to legislate for recognizing AK and NMSC as an occupational disease, which has the potential to improve access to compensation and drive preventative activities. 6. This report is a Call to Action for: I. The engagement of key stakeholders, including supranational institutions, national governments, trade organizations, employers, workers and patient organizations to drive change in prevention and protection of at-risk groups. II. Employers should be obliged to prevent outdoor worker's UV exposure from exceeding limit values, and to implement occupational skin cancer screening programmes among the at-risk workforce. III. Educational programmes for the outdoor workforce are needed to improve health literacy and drive behavioural change. IV. Nationally, steps to improve notifications and surveillance of skin cancers through both occupational services and public health programmes are required. V. Future research activities should focus on the precise definition of at-risk groups among outdoor workers through increased data gathering, including UV-dosimetry, and evaluation.

Sonography of full-thickness supraspinatus tears: comparison of patient positioning technique with surgical correlation

OBJECTIVE

Sonography has become a popular technique for the assessment of musculoskeletal disorders. Patient positioning is crucial to a thorough and accurate assessment of rotator cuff tendons. Two positions, the Crass and modified Crass, have been routinely used in the research and clinical settings to examine the supraspinatus tendon. Our study was a prospective trial to determine whether the Crass or the modified Crass position affords the most accurate measure of supraspinatus tears when compared with surgical findings.

SUBJECTS AND METHODS

Twenty-one patients with full-thickness supraspinatus tears underwent shoulder sonography in both the Crass and the modified Crass positions. Measurements of supraspinatus tears were performed in the sagittal and transverse dimensions. Patients subsequently underwent either arthroscopic or open supraspinatus repair. Intraoperative measurements were made in two dimensions and were compared with sonographic findings.

RESULTS

Sonography had 100% specificity in detecting full-thickness supraspinatus tears. No statistically significant difference was seen between the size of supraspinatus tears in the Crass and modified Crass positions and surgical findings in the transverse plane (p = 0.55 and 0.61, respectively). In the sagittal dimension, no statistically significant difference was seen between surgical findings and the Crass position (p = 0.14); however, a difference existed when the modified Crass position was used (p = 0.03).

CONCLUSION

Sonography reliably detects and quantifies supraspinatus tears. Both the Crass and the modified Crass positions reflected the true size of supraspinatus tears in the transverse plane. In the sagittal plane, the Crass position is the more useful to quantify supraspinatus tears because the modified Crass position overestimates the size of such tears.

Use of a calcium sulfate-calcium phosphate synthetic bone graft composite in the surgical management of primary bone tumors

Benign primary bone tumors are commonly treated with intralesional curettage with or without the use of surgical adjuvants. The reconstructive approach to the resulting contained bone defects is controversial, and clinical practice is varied. Synthetic bone substitutes may provide early mechanical support while minimizing the risks of disease transmission, nonunion, infection, and donor-site morbidity. Limited data exists regarding the use of calcium sulfate-calcium phosphate composite bone substitute for this purpose. The authors retrospectively reviewed the clinical outcomes of 24 patients with benign primary bone tumors who underwent intralesional curettage followed by reconstruction with a calcium sulfate-calcium phosphate composite bone substitute. Mean follow-up was 23 months. The most common diagnosis was giant cell tumor of bone. Six patients had upper-extremity tumors and 18 had lower-extremity tumors. Mean preoperative radiographic tumor volume was 41.0 cm(3). Mean volume of PRO-DENSE (Wright Medical Technology, Arlington, Tennessee) used in each patient was 15.6 cm(3). Mean time to full weight bearing for all patients was 7.3 weeks. Two patients sustained local tumor recurrences. No postoperative fractures occurred, and no complications occurred related to the use of the calcium sulfate-calcium phosphate composite. One case of deep infection occurred secondary to wound breakdown. The use of a calcium sulfate-calcium phosphate composite was associated with rapid biological integration and an early return to activities of daily living, with no composite-related complications. This technique is a viable option in the reconstruction of cavitary bone defects following intralesional curettage of primary benign bone tumors.

Ultrasound of intrinsic wrist ligament and triangular fibrocartilage injuries

OBJECTIVE

The objective of this study was to evaluate ultrasound as a diagnostic tool for investigating scapholunate and lunatotriquetral ligamentous and triangular fibrocartilage (TFC) tears. Ultrasound findings were compared to conventional arthrogram findings, as the reference gold standard.

DESIGN AND PATIENTS

In total 26 patients, 17 males and 9 females ranging in age from 17 to 35 (mean age, 34), were evaluated on referral for investigation of wrist pain. All patients were examined by high resolution ultrasound, using a 9-13 MHz transducer. All wrist ultrasound examinations were also compared to conventional tricompartmental arthrography, as the diagnostic gold standard reference.

RESULTS

All ten scapholunate tears confirmed on arthrography were detected on ultrasound. Two of 8 lunatotriquetral and 7 of 11 TFC tears were correctly diagnosed on ultrasound. Sensitivity of ultrasound diagnosis ranged from 25% for lunatotriquetral tears to 100% for scapholunate tears. No false positive results were recorded for any of the three examined structures.

CONCLUSION

The study results suggest that sonography is accurate for scapholunate tears, but is not accurate for evaluation of lunate-triquetral tears. It has intermediate accuracy for triangular fibrocartilage tears.

Imaging of chronic recurrent multifocal osteomyelitis

The disease of CRMO is a "great clinical and radiologic mimic. There are no specific clinical or laboratory findings and no pathognomonic imaging or pathologic features have been described. Because the disease is not well known by clinician, radiologist, and pathologist alike, it is likely to be more common than the literature implies. It has been suggested that the diagnosis of CRMO requires an interdisciplinary team approach dependent on the cooperation of the pediatrician, orthopedic surgeon, pathologist, and microbiologist. We strongly advocate the addition of the radiologist to this list. We believe that it is the informed radiologist who frequently suggests the correct diagnosis.

Ultrasound of the elbow

The elbow is an important synovial hinge joint of the upper extremity. This joint represents a common site of musculoskeletal symptomatology, affecting all age groups. The advantages of ultrasound imaging of the elbow include easy availability, multiplanar capability and the ability to assess structures dynamically. Patient symptomatology and site of maximal tenderness can be directly correlated with imaging findings. Comparison is easily made with the contralateral side. Particular strengths include the ability to assess para-articular structures, such as regional tendons and ligaments, in addition to assessment of joint effusions, loose bodies and regional bursae. With operator experience and excellent technique, ultrasound is a valuable imaging tool for assessment of disorders of the elbow joint.

Normal anatomy and common labral lesions at MR arthrography of the shoulder

MR arthrography of the shoulder is the most accurate imaging modality in demonstrating abnormalities of the glenoid labrum and associated structures. Tears of the labrum, the capsule or the gleno-humeral ligaments can lead to pain, catching, popping or instability. The anatomy of this region is complex. We present the normal anatomy of the glenoid labrum, biceps anchor and gleno-humeral ligaments together with their normal variants and then describe common labral-ligamentous pathologies.

Radiological manifestations of skeletal lymphoma

Lymphoreticular neoplasms primarily arise in extraskeletal locations with skeletal involvement usually secondary to hematogenous spread or by direct invasion from surrounding involved lymph nodes or soft tissues. Primary lymphoma of bone is relatively rare in comparison. Lymphoma encompasses Hodgkin's and non-Hodgkin's disease, Burkitt's lymphoma, and mycosis fungoides. Skeletal disease may present with symptoms localized to the site of bone involvement, as an incidental finding on imaging for other reasons, or as part of the staging of the disease. It is important that the radiologist is cognizant of the many presentations of skeletal lymphoma. We present a review of the radiological imaging of skeletal lymphoma with conventional radiographs, computed tomography, scintigraphic studies, and magnetic resonance imaging.

Ultrasonography of the lower extremity

Ultrasonography is a useful imaging tool for various soft tissue and joint pathologies affecting the lower extremity. This article reviews the normal sonographic appearance of muscles, tendons, ligaments, nerves, bone, and cartilage. The ultrasound imaging appearance of various pathologic conditions affecting the hip, thigh, knee, lower leg, ankle,and foot are illustrated. The advantages of ultrasonography are highlighted.

Sonography of the superomedial part of the spring ligament complex of the foot: a study of cadavers and asymptomatic volunteers

OBJECTIVE

To evaluate the ability of high-resolution sonography for assessing the thickness and echogenicity of the superomedial part of the normal spring ligament in the foot in cadavers and asymptomatic volunteers.

MATERIALS AND METHODS

The superomedial part of the normal spring ligament of four cadaveric feet was imaged with a high-resolution linear array transducer. Upon localization, the ligament was injected with 0.1% methylene blue with sonographic guidance. A posteromedial approach was used to dissect the feet immediately following injection to confirm accurate identification of the ligament. The bilateral ligaments in 40 asymptomatic adult volunteers were subsequently imaged.

RESULTS

Surgical dissection confirmed the accurate injection of methylene blue into all four cadaveric ligaments. The superomedial part of the normal spring ligament was identified bilaterally in all of the 40 asymptomatic volunteers, with a mean thickness of 3 mm in longitudinal short axes. The ligament was echogenic relative to surrounding fat, and it was thinner in women. Differences in ligament measurements with respect to age, sex, side (left vs. right) and foot dominance were not significant. The volunteers' height, weight and body mass index had a weakly positive correlation with ligament thickness.

CONCLUSION

High-resolution ultrasound can be used to identify and measure the thickness of the superomedial part of the normal spring ligament. The provided baseline measurements for the normal ligament could prove valuable when assessing the abnormal ligament.

Axial oblique MR imaging of the intrinsic ligaments of the wrist: initial experience

OBJECTIVE

To evaluate two separate MR sequences acquired in the axial oblique plane, parallel to the long axis of the scapholunate (SL) and lunotriquetral (LT) ligaments, to determine whether the addition of these sequences to the standard MR wrist examination improves visualization of the intrinsic ligaments, and the evaluation of their integrity. To our knowledge, this plane has not been described in the literature previously.

DESIGN AND PATIENTS

In total we evaluated 26 patients with chronic wrist pain or instability, referred for MR imaging following assessment by an orthopedic surgeon or physiatrist. All patients underwent initial conventional tri-compartment wrist arthrography, which served as the reference standard. This was immediately followed by MR arthrography, in the standard coronal and true axial planes, as well as in the axial oblique plane. The SL and LT ligaments were initially assessed for the presence or absence of tear, using the standard coronal and true axial sequences, and subsequently re-evaluated with the addition of the axial oblique planes.

RESULTS

A total of ten intrinsic ligament tears were identified with conventional arthrography: six SL and four LT tears. Five of the six SL tears were identified on the standard sequences. All six were diagnosed with the addition of the oblique sequences. There were three false-positive SL tears identified using standard MR imaging, and two false-positives with the addition of the oblique sequences. No LT tear was identified on standard sequences, whereas all four were confidently seen with the addition of oblique images. No false-positives of the LT ligament were recorded with either standard or axial oblique sequences.

CONCLUSION

The study suggests that the addition of axial oblique MR sequences helps identify tears to the intrinsic ligaments of the wrist, particularly the LT ligament. In addition, the axial oblique images assist in localization of the tear.

Sonography of intramuscular myxomas: the bright rim and bright cap signs

OBJECTIVE

The objective of this study was to retrospectively review sonographic images of pathologically proven soft tissue myxomas to determine whether a sonographic correlate to the bright rim and bright cap signs described in the magnetic resonance imaging literature is present.

METHODS

The study group consisted of 6 patients with pathologically proven soft tissue myxomas (1 man and 5 women; age range, 41-72 years; mean, 56.5 years). The available sonographic images for each subject were retrospectively reviewed by 2 authors (L.F. and K.F.), with agreement reached by consensus. Among other findings, images were also reviewed for a peripheral rim of increased echogenicity (termed the "bright rim sign") and for the presence of a triangular hyperechoic area adjacent to at least one of the poles of the mass (termed the "bright cap sign").

RESULTS

The bright rim and bright cap signs were seen in 5 (83%) of the 6 myxomas. The single case without the bright cap sign was not the same case as the one lacking the bright rim sign.

CONCLUSIONS

The sonographic bright rim and bright cap signs were associated with 5 (83%) of the 6 intramuscular myxomas. These findings correlate with their magnetic resonance imaging equivalents, which are well documented in the literature, due to muscle atrophy and adjacent fatty infiltration. Recognition of these features may assist in a more accurate sonographic diagnosis before biopsy.

Factors Influencing Radiology Residents' Fellowship Training and Practice Preferences in Canada

Purpose

The study aimed to examine the postresidency plans of Canadian radiology residents and factors influencing their fellowship choices and practice preferences, including interest in teaching and research.

Methods

Institutional ethics approval was obtained at McMaster University. Electronic surveys were sent to second to fifth-year residents at all 16 radiology residency programs across Canada. Each survey assessed factors influencing fellowship choices and practice preferences.

Results

A total of 103 (31%) Canadian radiology residents responded to the online survey. Over 89% from English-speaking programs intended to pursue fellowship training compared to 55% of residents from French-speaking programs. The most important factors influencing residents' decision to pursue fellowship training were enhanced employability (46%) and personal interest (47%). Top fellowship choices were musculoskeletal imaging (19%), body imaging (17%), vascular or interventional (14%), neuroradiology (8%), and women's imaging (7%). Respondents received the majority of their fellowship information from peers (68%), staff radiologists (61%), and university websites (58%). Approximately 59% planned on practicing at academic institutions and stated that lifestyle (43%), job prospects (29%), and teaching opportunities (27%) were the most important factors influencing their decisions. A total of 89% were interested in teaching but only 46% were interested in incorporating research into their future practice.

Conclusions

The majority of radiology residents plan on pursuing fellowship training and often receive their fellowship information from informal sources such as peers and staff radiologists. Fellowship directors can incorporate recruitment strategies such as mentorship programs and improving program websites. There is a need to increase resident participation in research to advance the future of radiology.

Resident Physicians' Perceptions of Diagnostic Radiology and the Declining Interest in the Specialty

RATIONALE AND OBJECTIVES

The relative competitiveness of radiology and the number of first-choice applicants to diagnostic radiology have steadily declined over the past decade. The purpose of this study was to identify factors contributing to the declining interest in diagnostic radiology as a career and to explore factors affecting specialty choice.

MATERIALS AND METHODS

A retrospective survey was distributed to resident physicians at a single academic center between July and August 2017. Participants identified factors affecting career choice and evaluated level of agreement with statements regarding radiology using 5-point Likert scales. Higher scores indicated stronger agreement.

RESULTS

One hundred and fifty-two resident physicians from Canada participated (21.5% response rate): 20 radiology and 132 nonradiology. Of the total, 27% were registered in postgraduate year (PGY) 1, 23% in PGY 2, 15% in PGY 3, 19% in PGY 4, and 16% in PGY 5, or above. Sixty-one percent of the respondents self-reported as female, 34% as male, and 5% as other/unknown. Of those in radiology, 40% self-reported as female, 55% as male, and 5% as other/unknown, compared to 64% female, 31% male, and 5% other/unknown in other specialties. Regardless of specialty, positive clinical/mentoring experiences strongly affected career choice. Radiology residents were attracted to diverse pathology (M = 4.5) and positive staff/resident interactions (M = 4.4). Nonradiology residents were deterred by lack of patient contact (M = 3.9) and dark work environment (M = 3.6). Resident physicians who had applied to radiology were more likely to report positive mentorship during medical school, disagree that technology will replace radiologists, and desire a higher income specialty (Wald = 56.6, p < 0.001). More recent graduates showed a higher level of concern regarding the potential negative impact of technology and outsourcing on the profession (F (3, 189) = 2.6, p = 0.05). Several trainees (21%) considered radiology, but lacked mentorship (52%) and identified job market concerns (29%).

CONCLUSION

More recent graduates are relatively more concerned about technology replacing radiologists, and radiology applicants have less concern about artificial intelligence replacing radiologists. As positive interactions with radiologists and mentorship are key influencers, our results advocate for early training exposure and reinforcement regarding the positive outlook of the profession.

Calcific myonecrosis and tenosynovitis: sonographic findings with correlative imaging

We report the sonographic appearance of a case of calcific myonecrosis and tenosynovitis with correlative plain radiography and CT findings. Calcific myonecrosis is a rare complication of previous trauma that presents as a tumor-like calcified mass years after an initial injury, most commonly affecting the anterior compartment of the lower leg. Although the clinical, radiographic, and MRI features of calcific myonecrosis have been well described, to our knowledge the sonographic appearance has not been reported previously in the literature.

Chronology of the Radiographic Appearances of the Calcium Sulfate-Calcium Phosphate Synthetic Bone Graft Composite Following Resection of Bone Tumors: A Follow-up Study of Postoperative Appearances

PURPOSE

The objective of the study was to characterize the radiographic appearance of graft resorption and new bone incorporation into a postresection defect of the calcium-sulfate calcium-phosphate synthetic bone graft composite following resection of benign bone tumours.

METHODS

Twenty-five patients who underwent treatment with the CaSO4/CaPO4 synthetic graft following bone tumour resection were retrospectively identified from our oncology database. Postoperative radiographs were assessed for: 1) combined partial graft resorption and ingrowth at the graft site; 2) complete graft resorption with complete incorporation of new bone into the defect. After chronologically grouping radiographs, the volume of graft material used to fill bony defects, radiographic evidence of complications, and patterns of resorption were recorded.

RESULTS

Partial resorption of graft material/partial ingrowth of new bone was seen in 21 patients at 2.5 months postoperatively. Complete resorption of graft with complete new bone incorporation at the graft site was seen in 94% of cases (15 of 16) by 10 months after surgery. Mean time to complete incorporation of new bone was 6.7 months. Time to resorption of the graft with new bone ingrowth was found to be related to the volume of graft used with smaller volumes showing earlier resorption. For all cases demonstrating resorption (21 of 21), the pattern observed was peripheral to central. Five patients developed complications, including tumour recurrence, cyst formation, and graft site infection.

CONCLUSION

Our study suggests a characteristic time and volume related radiographic pattern of resorption and new bone ingrowth with the CaSO4/CaPO4 synthetic graft. Findings that deviate from this pattern may represent complication and warrant additional follow-up.