Shoulder, hip, and knee arthrography needle placement using fluoroscopic guidance: practice patterns of musculoskeletal radiologists in North America.

OBJECTIVE: The aim of this study was to evaluate the range of techniques used by radiologists performing shoulder, hip, and knee arthrography using fluoroscopic guidance. MATERIALS AND METHODS: Questionnaires on shoulder, hip, and knee arthrography were distributed to radiologists at a national radiology meeting. We enquired regarding years of experience, preferred approaches, needle gauge, gadolinium dilution, and volume injected. For each approach, the radiologist was asked their starting and end needle position based on a numbered and lettered grid superimposed on a radiograph. RESULTS: Sixty-eight questionnaires were returned. Sixty-eight radiologists performed shoulder and hip arthrography, and 65 performed knee arthrograms. Mean experience was 13.5 and 12.8 years, respectively. For magnetic resonance arthrography, a gadolinium dilution of 1/200 was used by 69-71%. For shoulder arthrography, an anterior approach was preferred by 65/68 (96%). The most common site of needle end position, for anterior and posterior approaches, was immediately lateral to the humeral cortex. A 22-gauge needle was used by 46/66 (70%). Mean injected volume was 12.7 ml (5-30). For hip arthrography, an anterior approach was preferred by 51/68 (75%). The most common site of needle end position, for anterior and lateral approaches, was along the lateral femoral head/neck junction. A 22-gauge needle was used by 53/68 (78%). Mean injected volume was 11.5 ml (5-20). For knee arthrography, a lateral approach was preferred by 41/64 (64%). The most common site of needle end position, for lateral and medial approaches, was mid-patellofemoral joint level. A 22-gauge needle was used by 36/65 (56%). Mean injected volume was 28.2 ml (5-60). CONCLUSION: Arthrographic approaches for the shoulder, hip, and knee vary among radiologists over a wide range of experience levels.

Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings.

Groin injuries are common in athletes who participate in sports that require twisting at the waist, sudden and sharp changes in direction, and side-to-side ambulation. Such injuries frequently lead to debilitating pain and lost playing time, and they may be difficult to diagnose. Diagnostic confusion often arises from the complex anatomy and biomechanics of the pubic symphysis region, the large number of potential sources of groin pain, and the similarity of symptoms in athletes with different types or sites of injury. Many athletes with a diagnosis of "sports hernia" or "athletic pubalgia" have a spectrum of related pathologic conditions resulting from musculotendinous injuries and subsequent instability of the pubic symphysis without any finding of inguinal hernia at physical examination. The actual causal mechanisms of athletic pubalgia are poorly understood, and imaging studies have been deemed inadequate or unhelpful for clarification. However, a large-field-of-view magnetic resonance (MR) imaging survey of the pelvis, combined with high-resolution MR imaging of the pubic symphysis, is an excellent means of assessing various causes of athletic pubalgia, providing information about the location of injury, and delineating the severity of disease. Familiarity with the pubic anatomy and with MR imaging findings in athletic pubalgia and in other confounding causes of groin pain allows accurate imaging-based diagnoses and helps in planning treatment that targets specific pathologic conditions.

Musculoskeletal biopsy: utilization and provider distribution in the United States Medicare population.

RATIONALE AND OBJECTIVES: Physicians from many specialties perform musculoskeletal biopsy. Using the Medicare database, we sought to determine which specialties represent the physicians who are performing the majority. MATERIALS AND METHODS: Using the CMS physician supplier procedure summary master file for 1996-2003, we extracted all claims for biopsy procedure codes (including marrow aspiration, muscle biopsy, percutaneous bone biopsy, and open surgical biopsy) categorized by provider specialty, and we analyzed procedure volumes. RESULTS: Since 1996, the rate of utilization of percutaneous bone biopsy has remained stable. In 2003, marrow aspiration was most commonly performed by hematology/oncology (80,038, 57%), followed by medical oncology (23,428, 17%); radiologists performed 755 (0.5%). Muscle biopsies were predominantly performed by radiologists (4,761, 40%), followed by neurosurgery (591, 5%). Percutaneous bone biopsy was mostly performed by radiologists (14,830, 53%), but orthopedic surgeons, neurosurgeons, and hematology/oncology specialists performed a large minority (6,879, 2,296, and 1,048 respectively; in aggregate, 37%). From 1996 to 2003, radiologists performed 71% more muscle biopsies (2,788 to 4,761) and 60% more percutaneous bone biopsies (9,259 to 14,830). Although most specialties are performing fewer percutaneous bone biopsies (e.g., oncologists: 7,217 to 1,048, -85%), orthopedic surgeons are performing 247% more (1,983 to 6,879) and neurosurgeons are performing 2,343% more (94 to 2,296). CONCLUSION: Excluding marrow aspiration, radiologists perform the majority of percutaneous bone biopsies, and the volume is increasing in the U.S. Medicare population. The overall volume has remained relatively stable from 1996 to 2003; although medical specialties are performing fewer, the volume performed by surgeons is increasing rapidly.

Distal intersection tenosynovitis of the wrist: a lesser-known extensor tendinopathy with characteristic MR imaging features.

OBJECTIVE: To present the MRI imaging findings of extensor tenosynovitis at the distal intersection or crossover between the second (extensor carpi radialis longus (ECRL) and brevis (ECRB)) and third (extensor pollicis longus (EPL)) extensor compartment tendons, and the anatomical details that may play a role in the pathogenesis of this condition. DESIGN AND PATIENTS: The imaging studies and clinical records of five patients (three females and two males, with ages ranging between 22 and 78 years; mean age, 49 years) presenting with pain on the dorsal and radial aspect of the wrist were reviewed by two musculoskeletal radiologists in consensus. Three cases were identified serendipitously during routine clinical reading sessions; a follow-up computerized database search for additional cases reported in the prior two years yielded two additional cases. The overall number of cases screened was 1,031. The diagnosis of tendinopathy affecting the second and third compartment extensor tendons was made on the basis of MRI findings and clinical follow-up, or synovectomy. RESULTS: All patients showed signs of tenosynovitis: in four patients both the tendons of the second and third extensor compartments were affected; the fifth patient showed signs of tenosynovitis of the EPL tendon, and tendinosis of the extensor carpi radialis tendons. Three patients showed tenosynovitis proximal and distal to the point of intersection; and in two of them, a discrete point of constriction was appreciated at the crossover site in relation to the extensor retinaculum. Two patients showed tenosynovitis limited to the segment distal to the point of decussation. Tendinosis tended to follow the presence of tenosynovitis. In one of the patients, subtendinous reactive marrow edema in Lister's tubercle was noted. CONCLUSION: Distal intersection tenosynovitis may be related to the biomechanical pulley effect exerted by Lister's tubercle on the EPL tendon as it leaves the third compartment and crosses over the extensor carpi radialis tendons, as well as the constraining effect of the extensor retinaculum. These anatomical features determine the presence of characteristic MR imaging findings.

MR imaging of the postoperative meniscus: repair, resection, and replacement.

Meniscal surgery is one of the most common orthopedic procedures performed in clinical practice today. Increasing awareness of the importance of the meniscus in knee function and stability has resulted in abandonment of the once common complete meniscectomy in favor of meniscus-preserving surgeries and, in some circumstances, meniscal replacement. Although the accuracy of magnetic resonance imaging in the diagnosis of meniscal tears is well established, imaging of the postoperative meniscus has proved more challenging, with debate about the optimal imaging technique. This article discusses normal meniscal anatomy and biomechanics to serve as the background for understanding meniscal pathology and treatment. This is followed by a review of meniscal surgery, with emphasis placed on meniscal repair, partial meniscectomy, and meniscal transplantation. Finally, imaging modalities utilized in the assessment of the postoperative meniscus are reviewed, including their advantages and disadvantages.

Calcific Tendinosis: A Potential Mimicker of Malignancy on PET.

We report a case of a 53 year old female with breast cancer and elevated glucose activity at the left greater trochanter on PET imaging. Further imaging with CT and MRI showed that this focus of increased FDG activity on PET was calcific tendinosis of the gluteus medius tendon, which mimicked metastatic disease in this patient.