Musculoskeletal Radiologists Research Articles

Towards Achilles Tendon Injury Prevention in Athletes with Structural MRI Biomarkers: A Machine Learning Approach.

Recent advancements in artificial intelligence have proven their effectiveness in orthopaedic settings, especially in tasks like medical image analysis. This study compares human musculoskeletal radiologists to artificial intelligence in a novel, detailed, short, and cost-effective examination of Achilles tendon magnetic resonance images to uncover potential disparities in their reasoning approaches. Aiming to identify relationships between the structured assessment of the Achilles tendon and its function that could support injury prevention. We examined 72 athletes to investigate the link between Achilles tendon structure, as visualised in magnetic resonance images using a precise T2*-weighted gradient echo sequence with very short echo times, and its functional attributes. The acquired data were analysed using advanced artificial intelligence techniques and reviewed by radiologists. Additionally, we conducted statistical assessments to explore relationships with functional studies in four meaningful groups: dynamic strength, range of motion, muscle torque and stabilography. The results show notable linear or non-linear relationships between functional indicators and structural alterations (maximal obtained Spearman correlation coefficients ranged from 0.3 to 0.36 for radiological assessment and from 0.33 to 0.49 for artificial intelligence assessment, while maximal normalised mutual information ranged from 0.52 to 0.57 for radiological assessment and from 0.42 to 0.6 for artificial intelligence assessment). Moreover, when artificial intelligence-based magnetic resonance assessment was utilised as an input, the associations consistently proved more robust, or the count of significant relationships surpassed that derived from radiological assessment. Ultimately, utilising only structural parameters as inputs enabled us to explain up to 59% of the variance within specific functional groups. This analysis revealed that structural parameters influence four key functional aspects related to the Achilles tendon. Furthermore, we found that relying solely on subjective radiologist opinions limited our ability to reason effectively, in contrast to the structured artificial intelligence assessment. Cross-sectional studies.

Reliability of distal radius fracture classification systems: a CT based study.

To assess the reliability and reproducibility of AO/OTA, Frykman and Fernandez classification systems for distal radius fractures on CT. Four radiologists, including one radiology resident, two musculoskeletal radiology fellows and one radiology consultant independently evaluated CT scans of 115 patients with distal radius fractures and classified the fractures according to AO/OTA, Frykman and Fernandez classification system. To assess reproducibility, a second set of reading was done by two observers after an interval of six weeks. Interobserver reliability was calculated for each classification system using intraclass correlation coefficient (ICC) and using Light's modification of kappa. Intraobserver agreement was calculated using Cohen's kappa. Interobserver reliability using ICC showed fair agreement for AO/OTA (0.447) and Frykman (0.432) classification system and poor agreement for Fernandez (0.196) classification system. Interobserver agreement using kappa was moderate for AO/OTA fracture (0.447) classification into either of three types, while it was only slight for complete classification into type, group and subgroup (0.177). Interobserver agreement using kappa was slight for Fernandez (0.196) classification systems and moderate for Frykman classification system (0.406). Intraobserver agreement for AO/OTA classification system was moderate for observer 1 (0.449) and slight for observer 2 (0.162). Intraobserver agreement for Frykman classification system was substantial for observer 1(0.754) and moderate for observer 2 (0.496). Intraobserver agreement for Fernandez classification system was moderate for both the observers (0.333, 0.320). Currently there is no classification system that is fully reproducible. AO/OTA and Frykman classification systems performed better than Fernandez classification system in terms of interobserver reliability. However, Frykman classification system performed better than both AO/OTA and Fernandez classification system in terms of intraobserver reproducibility. Fernandez classification system had worst inter and intraobserver reliability in present study. Reliability and reproducibility of AO/OTA classification system decreased when fractures were divided into subgroups.

Concomitant Factors Associated With Tillaux-Chaput Fractures in Adults: A Case-Control Study.

Tillaux-Chaput fractures (TCFs) consist of fractures of the anterolateral distal tibia. They rarely occur in isolation in adults. When TCFs are missed, there is a risk of chronic pain, instability, and ankle osteoarthritis. This study aimed to identify which factors are related to the presence of TCFs in ankle injuries. A retrospective review of 1134 ankle fractures evaluated between 2013 and 2023 at a level 1 trauma center was performed. Inclusion criteria were patients aged ≥18 years, ankle radiographs and computed tomographic (CT) scan evaluation, and the presence of a TCF confirmed by CT scan. Exclusion criteria were prior ankle surgery, pilon, or distal tibial fractures. A musculoskeletal radiologist and a foot and ankle-trained orthopaedic surgeon classified the TCFs into type 1, an extraarticular avulsion; type 2, a fracture involving the incisura fibularis; and type 3, a fracture with impaction of the anterolateral tibial plafond. A matching control group of ankle fractures without TCF was created with a 1:2 ratio. The following variables were collected: sex, age (<50 vs >50 years), ankle dislocation or subluxation, Weber classification, Maisonneuve fracture, type of medial and posterior malleolar fracture, Lauge-Hansen classification, malleoli involved, and osteochondral lesion of the talus. Multivariate logistic regression was performed to detect which variables had an association with the TCF and their subtypes. P value <.05 was considered significant. A total of 481 ankle fractures had radiographs and CT scans available for evaluation, of which 83 (17.3%) had a TCF. Of these, 44.6% were type 1, 44.6% type 2, and 9.6% type 3. The mean age was 52.2 years; 66.3% were women. Six patients (7.2%) had an isolated TCF. Fifty-eight (69.9%), 50 (60.2%), and 62 (74.7%) ankles had involvement of the lateral, medial, and posterior malleolus, respectively. Age ≥50 years (OR 2.73, 95% CI 1.45-5.14) and pronation external rotation injuries (OR 2.94, 95% CI 1.43-6.06) had a significant association with TCF. Moreover, ankle dislocation or subluxation (OR 3.16, 95% CI 1.11-8.96) and the absence of posterior malleolar fracture (OR 5.97, 95% CI 1.65-21.6) were significantly associated with TCF type 2 and 3. In this study, age ≥50 years and pronation external rotation injuries were the unique independent risk factors for TCF. Furthermore, ankle dislocation or subluxation and the absence of posterior malleolar fractures increased the odds of having a more severe TCF. This study provides insights into the factors associated with TCF and its subtypes during adulthood.

MRI spine request form enhancement and auto protocoling using a secure institutional large language model

BACKGROUND CONTEXTSecure institutional large language models (LLM) could reduce the burden of non-interpretative tasks for radiologists. PURPOSEAssess the utility of a secure institutional LLM for MRI spine request form enhancement and auto-protocoling. STUDY DESIGN/SETTINGRetrospective study conducted from December 2023 to February 2024, including patients with clinical entries accessible on the electronic medical record (EMR). PATIENT SAMPLEOverall, 250 spine MRI request forms were analyzed from 218 patients (mean age = 55.9 years ± 18.9 [SD]; 108 women) across the cervical (n=56/250, 22.4%), thoracic (n=13/250, 5.2%), lumbar (n=166/250, 66.4%), and whole (n=15/250, 6.0%) spine. Of these, 60/250 (24.0%) required contrast and 41/250 (16.4%) had prior spine surgery/instrumentation. OUTCOME MEASURESPrimary–Adequacy of clinical information on clinician and LLM-augmented request forms were rated using a four-point scale. Secondary–Correct MRI protocol suggestion by LLM and first-year board-certified radiologists (Rad4 and Rad5) compared to a consensus reference standard. METHODSA secured institutional LLM (Claude 2.0) used a majority decision prompt (out of six runs) to enhance clinical information on clinician request forms using the EMR, and suggest the appropriate MRI protocol. The adequacy of clinical information on the clinician and LLM-augmented request forms was rated by three musculoskeletal radiologists independently (Rad1:10-years-experience; Rad2:12-years-experience; Rad3:10-years-experience). The same radiologists provided a consensus reference standard for the correct protocol, which was compared to the protocol suggested by the LLM and two first-year board-certified radiologists (Rad4 and Rad5). Overall agreement (Fleiss kappas for inter-rater agreement or % agreement with the reference standard and respective 95%CIs) were provided where appropriate. RESULTSLLM-augmented forms were rated by Rads 1–3 as having adequate clinical information in 93.6-96.0% of cases compared to 46.8-58.8% of the clinician request forms (p<0.01). Substantial interobserver agreement was observed with kappas of 0.71 (95%CI:0.67–0.76) for original forms and 0.66 (95%CI:0.61–0.72) for LLM-enhanced requests. Rads 1–3 showed almost perfect agreement on protocol decisions, with kappas of 0.99 (95%CI:0.94–1.0) for spine region selection, 0.93 (95%CI:0.86–1.0) for contrast necessity, and 0.93 (95%CI:0.86–0.99) for recognition of prior spine surgery. Compared to the consensus reference standard, the LLM suggested the correct protocol in 78.4% (196/250, p<0.01) of cases, albeit inferior to Rad4 (90.0%, p<0.01) and Rad5 (89.2%, p<0.01). The secure LLM did best in identifying spinal instrumentation in 39/41 (95.1%) cases, improved compared to Rad4 (61.0%) and Rad5 (41.5%) (both p<0.01). The secure LLM had high consistency with 227/250 cases (90.8%) having 100% (6/6 runs) agreement. CONCLUSIONSEnhancing spine MRI request forms with a secure institutional LLM improved the adequacy of clinical information. The LLM also accurately suggested the correct protocol in 78.4% of cases which could optimize the MRI workflow.

3D color-rendered MR neurography heatmaps in visualizing normal lumbosacral (LS) plexus and increasing conspicuity of LS plexopathy.

To determine whether color-rendered 3D MR neurography (MRN) images (heatmaps) improve diagnostic accuracy, reader confidence levels, and time savings to assess LS plexus lesions compared to the conventional grayscale images. A cross-sectional study included adults of all genders with randomly chosen MRNs of LS plexus and known reference standards of normal or neuropathy (plexopathy and radiculopathy). Heatmaps were constructed using 3D MRN STIR images and color rendered with higher intensity to yellow and lower intensity to darker-red colors in 1-2 min on average and were available on PACS for the readers. 2D plus 3D grayscale MIP images and 2D plus 3D MIP heatmaps were analyzed by four musculoskeletal radiologists (two faculty and two fellows) in two separate rounds blinded to the final diagnosis. Readers evaluated: neuropathy and number of nerves affected (neuropathy score: 0-normal; 1-one nerve affected; and 2-two or more nerves affected); final diagnosis; confidence levels; and time taken to evaluate the studies. Conger's kappa and paired t-test were used for analysis. Among 70 MRNs from 70 patients, there were 32 males and 38 females with average age ± SD of 54.8 ± 20.1 years and 49.9 ± 16.6 years, respectively. There were 30 normal and 40 LS plexus lesion scans. Interreader agreements for neuropathy scores were substantial to moderate on conventional imaging and heat maps (Conger's kappa: 0.65; 95% CI: 0.55, 0.73, and 0.59; 95% CI: 0.47, 0.69), respectively. The mean neuropathy score and final diagnosis accuracies were similar in both rounds 85.7% ± 0.1% vs 83.2% ± 0.1% (p = 0.13), and 83.6% ± 0.1% vs 80.0% ± 0.1%; p = 0.16), respectively. Time savings were significant when using heatmaps for all readers (p < 0.001). Time savings using heatmaps ranged from 57.7% to 74.6% and 56.3% to 75% of the original time for the fellows and faculty, respectively. Average confidence levels for neuropathy score significantly increased using heatmaps for one fellow and one faculty (p < 0.05), while average confidence levels for final diagnosis improved for both fellows and one faculty (p < 0.05). 3D color-rendered MRN heatmaps show comparable diagnostic accuracy to conventional MRN imaging but with significant time savings to identify LS plexus lesions. Question Do color-rendered 3D MRN images (heatmaps) improve accuracy, and confidence, and save time when assessing lumbosacral (LS) plexus lesions compared to conventional grayscale images? Findings 3D-rendered heatmaps showed comparable diagnostic accuracy with time savings ranging from 56.3% to 75%. Clinical relevance 3D color-rendered heatmaps increase time efficiency in evaluating MRNs of LS plexus, allowing for improved radiologist productivity and diagnostic confidence.

Relationship between the Articular Cartilage Thickness of the Patella and Trochlea in Trochlear Dysplasia Compared to Normal Knees

Abstract Introduction: Anterior knee pain is not an uncommon problem. A plethora of pathologies can cause anterior knee pain. Patellofemoral maltracking (trochlear dysplasia) is not an uncommon cause of anterior knee pain in adolescents and young adults. Aim: We hypothesize that there is an alteration of articular cartilage of the patella and trochlear in trochlear dysplasia. Materials and Methods: Magnetic resonance images of 86 knee joints were reviewed independently by two musculoskeletal radiologists. Standard magnetic resonance imaging (MRI) sequences were used in this study. Based on the Dejour classification for trochlear dysplasia, the patients were divided into normal, Type A, B, C, and D. The articular cartilage thickness of the patella and trochlea was measured and compared between the groups. Results: Out of the 86 MRI scans of the knees which were reviewed, 32 patients were male and 54 were female. The mean patient age was 21.9 years (range = 10–40). Sixty-six knee joints had trochlear dysplasia, with 15 patients classified into Dejour Type A, 13 in Type B, 31 in Type C, and 7 in Type D. There was no significant difference in the articular cartilage thickness of the lateral facet of the patella between all groups (ANOVA F = 1.43, P = 0.23). Conclusion: There was no significant difference in the articular cartilage thickness in the lateral facet of the patella and trochlea in patients with normal knee joints compared to those with trochlear dysplasia of Type A–D.

Assessing Chat Generative Pre-training Transformer’s Proficiency in Identifying, Diagnosing, and Managing Orthopedic Fractures

Abstract Background: The exploration of Chat generative pre-training transformer’s (GPT’s) applications in medicine is gaining momentum, with artificial intelligence, particularly ChatGPT, showing promise in enhancing orthopedic care. ChatGPT can assist clinicians by providing relevant information based on patient symptoms, medical history, and radiological findings, aiding in differential diagnosis, and suggesting appropriate imaging modalities. This study focuses on evaluating the effectiveness of ChatGPT-4 in diagnosing and managing common orthopedic fractures. Methods: This study involved inputting a diverse set of fracture images into the ChatGPT-4 model. The process commenced by prompting ChatGPT with four questions: “What does the radiograph show?” The second prompt instructed ChatGPT with the actual diagnosis, followed by inquiries on how a clinician should manage the condition and potential complications. All generated responses underwent grading by two authors (musculoskeletal radiologist and orthopedic trainee), utilizing a 5-point Likert scale. Intraclass correlation coefficient (ICC) analysis measurements were performed to assess inter-rater reliability. Descriptive statistical analysis was then employed to provide a comprehensive summary of the study’s findings. Results: ChatGPT demonstrated limitations in identifying diagnoses based on inputted X-ray images. However, it excelled in providing comprehensive information about fracture management and potential complications. There was excellent interobserver reliability with a kappa of 0.9. Conclusion: Our study underscores the utility of ChatGPT as a valuable tool for aiding in the management of common fractures, offering a comprehensive overview of diagnosis, management, and potential complications. The findings highlight its potential role as a supplementary resource in orthopedic practice.

Comparison of Shear-Wave Elastography USG and CT: Composition Analysis of Rectus Femoris Muscle in Healthy Adults and Chronic Kidney Disease Patients.

This study aimed to compare shear-wave elastography (SWE) USG and composition analysis of CT on the right mid-rectus femoris muscle (RF) in both healthy adults and chronic kidney disease (CKD) patients. Sixty-three healthy adults and 22 CKD patients were included. One musculoskeletal radiologist performed right RF SWE USG, while two radiologists measured shear-wave velocity (SWV) from the same SWE images. CT scan was performed, and muscle composition was measured using imageJ, categorized into four HU-based compositions. Interobserver agreement for SWV between two readers was evaluated. Correlations between SWV and CT compositions were analyzed using Pearson's or Spearman's correlation. SWV of healthy group was significantly higher than CKD group by each reader (p = 0.030 and 0.038). The percentage of low-density muscle was higher in CKD group than healthy group (p < 0.001), and the percentage of normal density muscle was higher in healthy group than CKD (p < 0.001) by each reader. Interobserver agreement of SWV by the two readers was almost perfect in both groups (k = 0.957-0.984, 0.959-0.993). There was a statistically significant correlation between SWV and the percentage of normal density muscle on CT in both healthy adults and CKD patient groups (Reader 1, r = 0.318-0.480, p = 0.001 and 0.024; Reader 2, r = 0.511-0.518, p < 0.001 and p = 0.013). SWV demonstrated a significant correlation with the percentage of normal density muscle on CT in both healthy adults and CKD patients by each reader. SWE provides a radiation-free approach that may offer an objective method for evaluating muscle quality, potentially making it an option for muscle monitoring.

The Utility of a Community-Based Knee Ultrasound in Detecting Meniscal Tears: A Retrospective Analysis in Comparison with MRI.

MRI is the gold standard for detecting meniscal tears; however, ultrasound may readily detect meniscal changes, obviating the need for MRI. We aim to (1) determine ultrasound sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in detecting meniscal changes, and (2) describe characteristic meniscal changes in US and their prevalence. A retrospective analysis of knee ultrasound scans for the presence of medial and lateral meniscal tears was conducted. Meniscal changes were characterized into five US appearances (cleft, diminutive, cyst, displaced fragment, and extrusion) by the consensus of two musculoskeletal radiologists. Ultrasound findings were then compared to MRI results. In total, 249 patients were included. Ultrasound sensitivity, specificity, PPV, NPV, and accuracy for medial meniscal tears were 79%, 97.3%, 95.3%, 86.6%, and 90%, respectively, and for lateral meniscal tears the ultrasound sensitivity, specificity, PPV, NPV, and accuracy were 63%, 99.5%, 96%, 93%, and 93.6%, respectively. The false negative and false positive rates for medial meniscal tears were 13.4% and 4.7%, respectively, and for the lateral meniscus, the false negative and false positive rates were 6.7% and 3.8%, respectively. Meniscal clefts were the most prevalent appearance in the medial meniscus followed by extrusions. Meniscal extrusions were the most prevalent appearance in the lateral meniscus followed by clefts. Community-based US is highly accurate in the detection of meniscal tears when compared with MRI, making it a valuable diagnostic imaging tool for detecting meniscal tears in a community setting where accessibility to MRI is limited or if there are MRI contraindications.

Evaluation of the reliability and accuracy of MRI for the diagnosis of meniscal ramp lesions.

Meniscal ramp lesions are a special type of meniscal injury that affects the periphery of the posterior horn of the medial meniscus and/or its meniscocapsular attachments, strongly associated with anterior cruciate ligament (ACL) tears. Due to their location, these lesions can be missed arthroscopically so it is essential to diagnose them on preoperative magnetic resonance imaging (MRI). To evaluate the accuracy of MRI in detecting meniscal ramp lesions in patients with ACL tears using arthroscopy as the reference standard. Two musculoskeletal radiologists, blinded to the surgical findings, retrospectively and independently evaluated 106 knee MRI scans for the presence of meniscal ramp lesions in non-consecutive patients who underwent arthroscopic ACL reconstruction between January 2019 and July 2022 by a single surgeon at one institution. Having arthroscopy as reference, the diagnostic sensitivity and specificity as well as the positive and negative predictive values (PPV/NPV) of the MRI scans were calculated. Cohen's kappa coefficient was used to test inter-observer reliability. A P value <0.05 was considered statistically significant. In the study group of 106 patients (72 men, 34 women; mean age = 33.84 ±13.12 years), 76 had an arthroscopy-confirmed meniscal ramp lesion, while 30 did not. The sensitivity and specificity of MRI for the detection of meniscal ramp lesion were 88% and 87%, respectively. The PPV and NPV were 94% and 74%, respectively. Inter-rater reliability was excellent (k = 0915). This study demonstrates that MRI can accurately detect meniscal ramp lesions.

Imaging characteristics of hip joint microinstability: a case-control study of hip arthroscopy patients.

Hip microinstability is a clinical entity increasingly recognized and treated but challenging to diagnose with a lack of objective criteria. This study assessed the prevalence and diagnostic accuracy of different imaging findings for hip microinstability on radiograph and MR. A retrospective case-control study of 224 hips treated with arthroscopic surgery by a single orthopedic surgeon, 112 hips with clinical microinstability and 112 controls without. Pre-operative radiograph and MRI/MRA imaging were evaluated by two musculoskeletal radiologists to assess morphological parameters and imaging signs reportedly associated with hip microinstability. Four imaging features reached significance as predictors of microinstability via three-step logistic regression: labral hyperplasia and decreased lateral center edge angle on MR (OR 2.45 and 0.93, respectively) and the absence of positive ischial spine sign and absence of osteophytes on radiographs (OR 0.47 and 0.28, respectively). Increased acetabular anteversion and absence of cam lesions were more likely in the microinstability group (p = 0.02 and 0.04, respectively), but not independent predictors. Labral tears, chondral loss, abnormal ligamentum teres, anterior capsule thinning, iliocapsularis to rectus femoris ratio, posterior crescent sign, cliff sign, and femoro-epiphyseal acetabular roof (FEAR) index were not associated with microinstabillity. Imaging features may be predictive of hip microinstability in some cases. Decreased LCEA, increased acetabular anteversion, and labral hyperplasia were associated with microinstability in this study, while many other published imaging findings were not. Imaging remains complementary, but not definitive, in the diagnosis of hip microinstability.

Musculoskeletal imaging fellowship program directors: A study of educational paths, and scholarly engagement in the United States

PurposeThe overall aim of the study is to analyze and provide a comprehensive understanding of the demographics, educational backgrounds, and scholarly activities of musculoskeletal imaging fellowship program directors across the United States. MethodsA list of all members of the Society of Skeletal Radiology was obtained and musculoskeletal imaging fellowship program directors across the US were included. Publicly available online sources were used to gather demographic and educational information about each musculoskeletal imaging fellowship program director, which included the online curriculum vitae from the program websites, Health Grades, Doximity, and Elsevier's Scopus database. Demographic and educational data including age, gender, educational background (medical school, residency, fellowship), additional degrees, academic rank, prior leadership positions, and metrics of scholarly activity were recorded. Fellowships in diagnostic musculoskeletal radiology along with additional degrees were recorded. A two-tailed unpaired t-test was used to calculate the difference between means of scholarly activity between male and female PDs. ResultsIn this study encompassing 92 programs across the United States, the majority (88) were dedicated to pure Musculoskeletal (MSK) Imaging Fellowship, while one each offered combined training in MSK and Body Imaging, MSK, and Emergency Imaging, MSK Sports, and Interventional Spine, and Pediatric MSK Imaging. Program directors were identified for 90 out of 92 programs, revealing a regional distribution of 29 in the South (31.5 %), 24 in the North East (26.1 %), 20 in the Midwest (21.74 %) and 19 in the West (20.65 %). Gender analysis unveiled a predominantly male representation, with 71 male directors compared to 17 female directors, while age ranged from 30 to 70 years, with a mean age of 47.17 ± 7.4 years. Medical school backgrounds predominantly featured MD degrees (80), followed by IMG (7) and DO (4) degrees, with the most common IMG source being India. Faculty positions were mainly distributed among Assistant Professors (35), Associate Professors (32), and Professors (11). Research output metrics showcased a mean of 41.943 publications and an h-index of 10.625. Extra degrees were obtained by 31 directors, with common additions being other fellowships, MBAs, MS degrees, and PhDs. Notably, some directors held previous or current leadership positions, while a few had completed residencies outside of Radiology or pursued fellowships beyond MSK Imaging. ConclusionMusculoskeletal imaging fellowship program directors across the United States are predominantly male, with approximately 8 % having graduated from international medical schools. The most common training pathway for these directors is completing a diagnostic radiology residency followed by a musculoskeletal radiology fellowship. This study highlighted the gender disparity within this leadership group and emphasized the diverse educational backgrounds that contribute to the field of musculoskeletal imaging.

Ranking the Relative Importance of Image Quality Features in CT by Consensus Survey

ObjectiveThis study sought to determine consensus opinions from subspecialty radiologists and imaging physicists on the relative importance of image quality features in CT. MethodsA prospective survey of subspecialty radiologists and medical physicists was conducted to collect consensus opinions on the relative importance of ten image quality features: axial sharpness, blooming, contrast, longitudinal sharpness, low contrast axial sharpness, metal artifact, motion, noise magnitude, noise texture, and streaking. The survey was first sent to subspecialty radiologists in volunteer leadership roles in the American College of Radiology and Radiological Society of North America, thereafter relying on snowball sampling. Surveyed subspecialties were abdominal, cardiac, emergency, musculoskeletal, neuro, pediatric, and thoracic radiology, and medical physics. Individual respondents’ ratings were normalized for calculation of mean normalized ratings and priority rankings for each feature within subspecialties. Also calculated were intraclass correlation coefficients across image quality features within subspecialties, and analysis of variance across subspecialties within each feature. ResultsMost subspecialties had moderate to excellent intraclass agreement. For every radiology subspecialty except musculoskeletal, motion was the most important image quality feature. There was agreement across subspecialties that axial sharpness and contrast are only moderately important. There was disagreement across subspecialties on the relative importance of noise magnitude. Blooming was highly important to cardiac radiologists, and noise texture was highly important to musculoskeletal radiologists. ConclusionImage quality preferences differ based on clinical tasks and challenges in each anatomical radiology subspecialty. CT image analysis and development of quantitative measures of quality and protocol optimization—and related policy initiatives—should be specific to radiology subspecialty.

Diagnostic Accuracy of Pre-operative Percutaneous Synovial Biopsy and Aspirate Compared with Open Biopsy for Prosthetic Shoulder Infections

BackgroundShoulder arthroplasty revision is associated with a high prevalence of prosthetic infection, and diagnosis remains difficult. The primary aim of the study was to determine the diagnostic accuracy of percutaneous synovial biopsy (PSB) and joint aspiration compared with open culture results in detecting infection in revision shoulder arthroplasty. The second aim was to determine whether biopsy location within the shoulder was associated with culture status. MethodsThis was a multicenter prospective cohort study involving four sites and 69 patients undergoing revision shoulder arthroplasty. The cohort was 57% female with a mean age of 64 years. Preoperative fluoroscopic-guided PSB’s and aspirates were carried out by a musculoskeletal radiologist prior to revision shoulder arthroplasty. The original prostheses consisted of hemiarthroplasties, total shoulder arthroplasties (TSA), resurfacing TSA, reverse shoulder arthroplasties (RSA), and antibiotic spacers. Six synovial tissue biopsies from separate regions in the shoulder were obtained both preoperatively and intra-operatively. The shoulder joint was aspirated, and synovial fluid collected, if available. Infection was considered positive in the setting of two or more matching positive cultures. The PSB cultures were considered “true positive” if the PSB cultures matched the open biopsy cultures. ResultsNineteen percent had positive infection based on PSB and 23% had confirmed culture positive infections based on intra-operative biopsy. The diagnostic accuracy of PSB compared with open biopsy was as follows: sensitivity 0.37 (95% CI 0.13-0.61), specificity 0.81 (95% CI 0.7-0.91), positive predictive value 0.37 (95% CI 0.13 – 0.61), negative predictive value 0.81 (95% CI 0.70-0.91), positive likelihood ratio 1.98 and negative likelihood ratio 0.77. Of the 71 patients, aspiration yielded synovial fluid in 33 patients. Preoperative aspirates detected no infections confirmed positive by open biopsy and correctly identified 81% of absent infections. The diagnostic accuracy of aspirates compared with open biopsy was as follows: sensitivity 0%, specificity 0.81 (95% CI 0.66-0.96), positive predictive value 0%, negative predictive value 0.78 (95% CI 0.63-0.93). Biopsy location within the shoulder was not associated with infection status. DiscussionPreoperative aspiration detected none of the infections proven positive via open biopsy. Although PSB was superior to synovial fluid aspirate, poor likelihood ratios suggests that PSB is not useful as an isolated test in the preoperative workup of the potentially infected patient.Biopsy location was not associated with culture status suggesting that the capsule is uniformly infected, and the location of tissue biopsies does not appear to matter.

Prospective Trial of Sacroiliac Joint Fusion Using 3D-Printed Triangular Titanium Implants: 5-Year Follow-Up.

Prospective, multicenter, single arm study with 5-year follow up. To report long-term (5-year) safety, effectiveness, and radiographic outcomes after sacroiliac (SI) joint fusion (SIJF) with 3D-printed triangular titanium implants (TTI) and compare them with solid titanium plasma spray coated implants. A large literature base supports minimally invasive SIJF with TTI for chronic SIJ dysfunction. SIJF with TTI was performed in 51 subjects and scheduled follow-up occurred at 3, 6, 12, 24 and 60 months. Postoperative visits included quality of life questionnaires and functional tests. A high-resolution CT scan was performed at either 6 or 12 months, and again at 60 months. All CT scans were interpreted by an independent musculoskeletal radiologist. 5-year follow-up was available in 36 of 51 subjects (71%). At 5 years, improvements in SI joint pain (58.1 points [0-100 scale]), SIJ-related disability (Oswestry Disability Index [ODI], 25.4 points) and quality of life (EuroQOL 5D, 0.24 points, and EuroQOL visual analog scale, 13.4 points) were sustained and showed no signs of diminution. The percentage of patients using opioids for SIJ pain decreased markedly from baseline (57%) to 5 years (17%). Physical function tests showed persistent improvements from baseline. There was no evidence of device breakage, migration or subsidence and few late adverse events occurred attributable to the device. Independent analysis of CT scans showed bone opposed to implants in all cases, and evidence of bone bridging in 90% of cases, and no evidence of radiolucency or other adverse bone reactions. Prospective 5-year follow-up showed that SIJ fusion using 3D-printed TTI resulted in immediate, marked, and persistent improvements in pain and quality of life, with improved physical function, reduced opioid use, and a low rate of revision surgery. Radiographic evidence showed implant integration and joint fusion. Level II.

Radiography versus computed tomography for osseous staging of Kienböck's disease.

This retrospective study compared the diagnostic accuracy of conventional radiography (CR) and computed tomography (CT) in classifying Kienböck's disease (KD) according to Lichtman staging. Besides age, cartilage condition and vascularity, bone morphology is important in choosing the most appropriate treatment in KD. In 278 patients, two musculoskeletal radiologists performed a consensus reading of 281 lunate necroses according to the Lichtman classification, based on CR and CT. Stage IIIc was most common in CR (43%) and CT (61%), followed by stage IIIa for CR (25%) and stage IV for CT (15%). In 67%, KD was classified as the same in both modalities. The KD stage had to be upgraded in CT in 34% of cases, notably with stage IIIa progressing to IIIc in 24 out of 69 patients and stage IIIb to IIIc in 23 out of 38 cases. Overall, the Lichtman score was significantly higher on CT. The findings suggest that CT is better than CR in accurately determining the stage of KD stage, indicating a potential shift towards more surgical salvage procedures.Level of evidence: III.

Intra-articular Corticosteroid Injection for Adhesive Capsulitis: A Randomized Controlled Trial

Background Adhesive capsulitis is a common cause of glenohumeral joint pain and stiffness that significantly interferes with patients' lives and ability to work. Since no specific treatment options have been well established, this research examines arthrographic injection of the glenohumeral joint with steroid and local anesthetic versus local anesthetic alone for the treatment of adhesive capsulitis. Methods A double-blinded randomized controlled trial was conducted with patients diagnosed with idiopathic adhesive capsulitis. They were randomized to one of two groups: (1)local anesthetic plus steroid or (2)local anesthetic. A musculoskeletal radiologist performed all of the image-guided injections using a standardized patient-blinded technique. Outcome measures included shoulder range of motion, grip strength, and scores on the Shoulder Pain and Disability Index (SPADI), Constant Score, and Visual Analog Scale (VAS) for pain. Evaluations occurred at baseline and 3-, 6- and 12-weeks post-injection. Results Thirty-seven patients were enrolled in the study. There was no significant improvement in shoulder range of motion and grip strength with local anesthetic plus corticosteroid injection compared to local anesthetic alone. Shoulder range of motion was better at all time points for the group with local anesthetic alone. Both groups showed significant improvements in their VAS and SPADI pain scores at all post-injection follow-up appointments (p=.011). The SPADI results showed significantly better disability scores for the local anesthetic plus steroid group (p=.012) and improved pain scores from baseline at all follow-up times (p=.011), whereas the local anesthetic group had significant pain relief for only the first 3 weeks (p=.050). Conclusion Intra-articular injection with local anesthetic plus steroid was beneficial in improving pain but not range of motion when compared to injection with local anesthetic alone.

Anatomical variants of the medial synovial fold of the posterior cruciate ligament: morphological classification based on magnetic resonance imaging of the knee.

The medial synovial fold of the posterior cruciate ligament is one of the synovial plicae of the knee joint. The objective of this study was to assess the necessity of reporting the appearance of the medial synovial fold of the posterior cruciate ligament on magnetic resonance imaging of the knee joint and its correlation with side and sex. Patients with normal knee structure on magnetic resonance imaging (MRI) scans between 2018 and 2023 were included in this retrospective study. MRI scans of the knee joints were retrospectively reviewed by two musculoskeletal radiologists independently. The medial synovial fold of the posterior cruciate ligament was divided into three types according to the imaginary line drawn between the lateral border of the medial femoral condyle and the medial tibial intercondylar tubercle. The study included 1147 patients, of whom 478 (41.7%) were female and 669 (58.3%) were male. Among these patients, 580 (50.6%) had a right knee scan, and 567 (49.4%) had a left knee scan. The age range was 15-35 years for both sexes. The frequency of the medial synovial fold types in all patients was as follows: Type A (30.1%), Type B (55.4%) and Type C (14.5%). There was a high level of agreement between the observers. There was a statistically significant difference in the frequency of medial synovial fold types between sexes, with men exhibiting a greater prevalence. Magnetic resonance imaging (MRI) of the knee joint revealed the medial synovial folds of the posterior cruciate ligament (PCL). The most common was Type B (55.4%), followed by Type A (30.1%) and Type C (14.5%) among the MSF types. No statistically significant difference was found between the right and left knees for any of the MSF types.

Syndesmotic and Deltoid Injuries: Companions or Coincidences.

Syndesmotic complex injuries are supposedly associated with injuries to the deltoid ligament (DL) complex. Several syndesmosis classifications take DL injuries into account when rating the stability of the syndesmotic injury. Still, no study has yet assessed the frequency and severity of DL injuries in unstable syndesmotic injuries. The aim of this retrospective cohort study was to assess both the severity of the syndesmotic and DL injury in patients undergoing surgery for an unstable syndesmotic injury. The integrity of the syndesmotic and DL complex of 37 patients were assessed on MRI by 2 musculoskeletal radiologists. Eligible were adult patients with an acute, isolated, unstable syndesmotic injury (ligamentous or bony avulsions) who underwent surgery. The DL complex was classified as having 3 superficial (TNL/TSL/TCL) and 2 deep (aTTL/pTTL) components. Grade 0 indicated an intact ligament; grade I showed a periligamentous edema; grade II a partial tear presenting as laxity, irregular contour, or partial discontinuity with concomitant hyperintense signaling; grade III a complete tear; or grade IV in case of an avulsion fracture. Frequency and severity of DL injuries were assessed, and possible injury combinations analyzed using an h-cluster analysis and Mann-Whitney U test. Mean severity (grade 0-3) was 2.6 ± 0.8 for the syndesmotic complex and 1.6 ± 1.1 for the DL (superficial 1.5 ± 1.1, deep 1.6 ± 1.1). Seven patients (19%) had no (n = 3; 8%) or minor (grade 1: n = 4; 11%) DL injuries. Overall, 2 different patient clusters and 4 separate ligament clusters were identified. Unstable syndesmotic injuries can occur isolated or with an accompanying DL injury. There appears to be a great heterogeneity between the severity of syndesmotic and deltoid ligament injuries.

Optimization of magnetic resonance imaging of the hand

BACKGROUND: Magnetic resonance imaging is one of the leading imaging modalities of the musculoskeletal system. However, when imaging the hand, major problems in magnetic resonance imaging include the lack of specialized coils and reliable fixation devices for the hand, uncomfortable patient posture, motion artifacts, and small anatomical structures in the wrist. These factors inevitably lead to incorrect interpretation. AIM: To improve the quality of magnetic resonance imaging of the hand by developing an approach to coil selection, scanning protocol, and hand positioning and fixation. MATERIALS AND METHODS: A positioning device was developed to prevent hand movements. Two types of coils were evaluated. Magnetic resonance images were evaluated comparatively, as well as by a musculoskeletal radiologist. RESULTS: А head coil is more appropriate when scanning the entire hand, for example, in rheumatic diseases. A knee coil is more appropriate when studying smaller anatomical structures (including the wrist) owing to a smaller field of view and higher resolution. Based on the obtained data, guidelines for the selection of scanning parameters, sequences, and coils for magnetic resonance imaging of the hand were formulated. To prevent motion artifacts, a special fixation device of the patient’s hand was introduced. CONCLUSION: Certain factors directly affect the qualitative magnetic resonance imaging study of the hand, such as safety protocols, scanning parameters, and hand fixation. The guidelines presented in this study and the use of the developed specialized fixation device may improve the quality of magnetic resonance imaging of the hand.