A needs assessment of musculoskeletal fellowship training: a survey of practicing musculoskeletal radiologists.

OBJECTIVE: The purpose of this study was to conduct a needs assessment of musculo-skeletal radiologists regarding their musculoskeletal training experience and attitude toward a standardized musculoskeletal fellowship curriculum. MATERIALS AND METHODS: An anonymous survey was sent to the Society of Skeletal Radiology membership querying musculoskeletal radiologists' practice patterns, fellowship program, curriculum, and modes of learning. RESULTS: Of 216 respondents (26% response rate), 87% were musculoskeletal fellowship trained. The majority performed MRI, CT, and radiography (99%); arthrography (95%); spine MRI (77%); pediatric musculoskeletal imaging (75%); musculoskeletal ultrasound (63%); and biopsies (62%). During fellowship, 72% read spine MRI; 74% pediatric musculo-skeletal imaging, and 49% musculoskeletal ultrasound (49%); 33% received no spine procedural training. Most felt comfortable performing arthrography, joint injections, and bone and soft-tissue biopsies but not spine biopsies. Of the total, 33% received a curriculum and 67% had no formal feedback and 56% did not evaluate their program. The highest rated program features were teaching by attending physicians (69%), case variety (54%), and procedural training (49%). The lowest rated features were lack of curriculum (57%), lack of structured learning (48%), and lack of mentoring (24%). The favorite mode of learning was one-on-one readout with attending physicians (90%), and 85% agreed that a standardized musculoskeletal fellowship curriculum would benefit musculoskeletal training. CONCLUSION: Although musculoskeletal radiologists believe they were adequately trained for practice, there are perceived deficiencies in spine MRI, pediatric musculoskeletal imaging, and musculoskeletal ultrasound. A standardized musculoskeletal fellowship curriculum would provide improved structure and a defined educational program. Clear expectations, performance assessment, feedback, and programmatic evaluation should be core elements of the training of every musculoskeletal fellow.

Treatment of rotator cuff tears in older individuals: a systematic review.

BACKGROUND: Rotator cuff disease is common in older adults and may compromise health status and functional independence. However, little evidence exists to guide the treatment of rotator cuff tears (RCTs) in the older patient. This study evaluated the evidence regarding treatment of RCTs in patients with a mean age of 60 years or older. METHODS: PubMed, SCOPUS, Science Citation Index (Web of Knowledge), Sport Discus, CINAHL, The Cochrane Controlled Trials registry, podium and poster presentations, proceedings, and abstracts from American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and American Shoulder and Elbow Surgeons were searched for published and unpublished studies from 1966 to 2009. Inclusion criteria were English language, level of evidence I to III or greater, a full-thickness RCT, and treatment (surgery, physical therapy, injections, medications, or observation). Exclusion criteria included purely retrospective studies, isolated tears of the subscapularis, partial RCTs, revision surgery, and grafting or tendon transfer procedures. The blinded studies were independently evaluated using principles in the CONSORT (Consolidated Standards of Reporting Trials, 2001) statement and then collated by level of evidence and treatment strategy. RESULTS: Eight studies (1 level I, 4 level II, and 3 level III) evaluated treatment outcomes in patients aged older than 60 years. Review of the included operative studies suggests possible efficacy with operative intervention. However, heterogeneity of these studies and bias did not allow for a valid consensus on the best treatment approach. CONCLUSIONS: There is insufficient evidence to suggest efficacy in operative or nonoperative treatment of RCTs in older patients. The results presented here suggest possible favorable outcomes with operative management of RCTs.

Time to return to play after high ankle sprains in collegiate football players: a prediction model.

BACKGROUND: Determining the severity of high ankle sprains in athletes and predicting the time that an athlete can return to unrestricted sport activities following this injury remain significant challenges. PURPOSE: The objectives of this study were (1) to determine if objective measurements of injury severity after high ankle sprains could predict the time to return to play in Division I football players and (2) to determine whether physical examination or diagnostic musculoskeletal ultrasound was more predictive of return to play. The hypothesis was that objective measures of injury severity of a high ankle sprain can be predictive of time to return to athletic participation in collegiate football players. STUDY DESIGN: Prospective case series. METHODS: Twenty consecutive Division I collegiate football players with a diagnosis of a grade I high ankle sprain (syndesmosis sprain without diastasis) were studied. Two clinical measurements of injury severity were determined: the height of the zone of injury on physical examination and the height of the zone of injury as defined by diagnostic musculoskeletal ultrasound examination. All athletes followed a standardized treatment program and return-to-play criteria. A regression model and Cox proportional hazards model were developed to determine time to return to unrestricted play as a function of injury severity and player position. RESULTS: Physical examination but not ultrasound was significantly correlated with time to return to play. Regression and Cox analyses revealed that injury severity on physical examination and player position were significant predictors of time to return to unrestricted play following high ankle sprain. CONCLUSIONS: Injury severity on physical examination and player position are associated with the time to return to unrestricted athletic activity after injury. A model based on the data can be applied to help predict the time to return to unrestricted play in Division I collegiate football players following high ankle sprain.

When do rotator cuff repairs fail? Serial ultrasound examination after arthroscopic repair of large and massive rotator cuff tears.

BACKGROUND: Despite advances in arthroscopic repair of rotator cuff tears, recurrent tears after repair of large and massive tears remain a significant clinical problem. The primary objective of this study was to define the timing of structural failure of surgically repaired large and massive rotator cuff tears by serial imaging with ultrasound. The secondary objective of this study was to investigate the association between recurrent tears and clinical outcome after rotator cuff repair. HYPOTHESIS: Recurrent tear after arthroscopic repair of large rotator cuff tears is more likely to occur late (>3 months) in the postoperative period and will be associated with inferior clinical outcome scores. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Twenty-two consecutive patients with large (>3 cm) rotator cuff tears underwent arthroscopic repair with a standardized technique. Serial ultrasound examinations were performed at 2 days, 2 weeks, 6 weeks, 3 months, 6 months, 12 months, and 24 months after surgery. Western Ontario Rotator Cuff (WORC) Index scores were also collected at these time points. RESULTS: Nine (41%) of the 22 arthroscopically repaired rotator cuff tears demonstrated recurrent tears. Seven of the 9 retears occurred within 3 months of surgery, and the other 2 occurred between 3 and 6 months. No retears occurred after 6 months. At 24-month follow-up, WORC scores favoring intact rotator cuffs over retears approached statistical significance (mean WORC intact 123.9 vs retear 659.8; P = .07). CONCLUSION: Recurrent rotator cuff tears are not uncommon after arthroscopic repair of large and massive tears. These recurrent tears appear to occur more frequently in the early postoperative period (within the first 3 months) and are associated with inferior clinical outcomes.

Bone density of the greater tuberosity is decreased in rotator cuff disease with and without full-thickness tears.

BACKGROUND: Despite the high prevalence of rotator cuff disease in the aging adult population, the basic mechanisms initiating the disease are not known. It is known that changes occur at both the bone and tendon after rotator cuff tears. However, no study has focused on early or "pretear" rotator cuff disease states. The purpose of this study was to compare the bone mineral density of the greater tuberosity in normal subjects with that in subjects with impingement syndrome and full-thickness rotator cuff tears. MATERIALS AND METHODS: Digital anteroposterior shoulder radiographs were obtained for 3 sex- and age-matched study groups (men, 40-70 years old): normal asymptomatic shoulders (control), rotator cuff disease without full-thickness tears (impingement), and full-thickness rotator cuff tears (n = 39 per group). By use of imaging software, bone mineral densities were determined for the greater tuberosity, the greater tuberosity cortex, the greater tuberosity subcortex, and the cancellous region of the humeral head. RESULTS: The bone mineral density of the greater tuberosity was significantly higher for the normal control subjects compared with subjects with impingement or rotator cuff tears. No differences were found between the two groups of patients with known rotator cuff disease. The greater tuberosity cortex and greater tuberosity subcortex outcome measures were similar. CONCLUSION: Bone mineral changes are present in the greater tuberosity of shoulders with rotator cuff disease both with and without full-thickness tears. The finding of focal diminished bone mineral density of the greater tuberosity in the absence of rotator cuff tears warrants further investigation.

Shoulder kinematics in patients with full-thickness rotator cuff tears after a subacromial injection.

The purpose of this study was to test the hypothesis that scapulohumeral rhythm (SHR) is altered in patients with full-thickness rotator cuff tears due to pain. Fifteen subjects (mean age, 60.2 +/- 8.9 years; mean height, 1.72 +/- 0.10 m; mean weight, 85.43 +/- 18.32 kg) performed humeral elevation in the 3 planes before and after a lidocaine injection. Pain was assessed by use of a visual analog scale, and data were collected with an electromagnetic tracking system. Three-dimensional scapular kinematics (scapulothoracic motion) and glenohumeral elevation were assessed. A linear regression model was used to calculate SHR (ratio of scapulothoracic motion to glenohumeral elevation) for equal phases of elevation (I, II, and III) and lowering (IV, V, and VI). Pain was significantly reduced (P