The International Skeletal Society: a look back at 50 years of multidisciplinary expertise, collaboration, and education in musculoskeletal health and disease.

Multidisciplinary collaboration and radiology-pathology correlation are key components to advancing our knowledge and understanding of musculoskeletal disease and improving clinical care. The International Skeletal Society was founded on this principle and in its 50-year history it has successfully cultivated a globally recognized and respected Annual Meeting and Refresher Course to foster interest and share expertise in musculoskeletal disorders. The Society's consistent efforts for outreach and intersociety connections with MSK societies around the world have further strengthened its heritage. This look back on the Society's first 50 years recounts how it all started, where it has been, and provides insights on its promising future, not only in its support for education and scientific discovery, but also in its enrichment of precision medicine.

Does the presence of macroscopic intralesional fat exclude malignancy? An analysis of 613 histologically proven malignant bone lesions.

OBJECTIVE: To determine if macroscopic intralesional fat detected in bone lesions on CT by Hounsfield unit (HU) measurement and on MRI by macroscopic assessment excludes malignancy. MATERIALS AND METHODS: All consecutive CT-guided core needle biopsies (CNB) of non-spinal bone lesions performed at a tertiary center between December 2005 and September 2021 were reviewed. Demographic and histopathology data were recorded. All cases with malignant histopathology were selected, and imaging studies were reviewed. Two independent readers performed CT HU measurements on all bone lesions using a circular region of interest (ROI) to quantitate intralesional fat density (mean HU < -30). MRI images were reviewed to qualitatively assess for macroscopic intralesional fat signal in a subset of patients. Inter-reader agreement was assessed with Cronbach's alpha and intraclass correlation coefficient. RESULTS: In 613 patients (mean age 62.9 years (range 19-95 years), 47.6% female), CT scans from the CNB of 613 malignant bone lesions were reviewed, and 212 cases had additional MRI images. Only 3 cases (0.5%) demonstrated macroscopic intralesional fat on either CT or MRI. One case demonstrated macroscopic intralesional fat density on CT in a case of metastatic prostate cancer. Two cases demonstrated macroscopic intralesional fat signal on MRI in cases of chondrosarcoma and osteosarcoma. Inter-reader agreement was excellent (Cronbach's alpha, 0.95-0.98; intraclass correlation coefficient, 0.90-0.97). CONCLUSION: Malignant lesions rarely contain macroscopic intralesional fat on CT or MRI. While CT is effective in detecting macroscopic intralesional fat in primarily lytic lesions, MRI may be better for the assessment of heterogenous and infiltrative lesions with mixed lytic and sclerotic components. CLINICAL RELEVANCE STATEMENT: Macroscopic intralesional fat is rarely seen in malignant bone tumors and its presence can help to guide the diagnostic workup of bone lesions. KEY POINTS: • Presence of macroscopic intralesional fat in bone lesions has been widely theorized as a sign of benignity, but there is limited supporting evidence in the literature. • CT and MRI are effective in evaluating for macroscopic intralesional fat in malignant bone lesions with excellent inter-reader agreement. • Macroscopic intralesional fat is rarely seen in malignant bone lesions.

Older Tissue Age Derived From Abdominal Computed Tomography Biomarkers of Muscle, Fat, and Bone Is Associated With Chronic Conditions and Higher Mortality.

OBJECTIVE: To determine whether body composition derived from medical imaging may be useful for assessing biologic age at the tissue level because people of the same chronologic age may vary with respect to their biologic age. METHODS: We identified an age- and sex-stratified cohort of 4900 persons with an abdominal computed tomography scan from January 1, 2010, to December 31, 2020, who were 20 to 89 years old and representative of the general population in Southeast Minnesota and West Central Wisconsin. We constructed a model for estimating tissue age that included 6 body composition biomarkers calculated from abdominal computed tomography using a previously validated deep learning model. RESULTS: Older tissue age associated with intermediate subcutaneous fat area, higher visceral fat area, lower muscle area, lower muscle density, higher bone area, and lower bone density. A tissue age older than chronologic age was associated with chronic conditions that result in reduced physical fitness (including chronic obstructive pulmonary disease, arthritis, cardiovascular disease, and behavioral disorders). Furthermore, a tissue age older than chronologic age was associated with an increased risk of death (hazard ratio, 1.56; 95% CI, 1.33 to 1.84) that was independent of demographic characteristics, county of residency, education, body mass index, and baseline chronic conditions. CONCLUSION: Imaging-based body composition measures may be useful in understanding the biologic processes underlying accelerated aging.

Ultrasound Measurement of Femoral Articular Cartilage Thickness Before and After Marathon Running.

OBJECTIVE: The purpose of this study was to use ultrasonography to measure femoral articular cartilage thickness changes during marathon running, which could support MRI studies showing that deformation of knee cartilage during long-distance running is no greater than that for other weight-bearing activities. MATERIALS AND METHODS: Participants included 38 marathon runners with no knee pain or history of knee injury, aged 18-39. Ultrasound images of the femoral articular cartilage were taken two hours before and immediately after the race. Femoral articular cartilage thickness was measured at both the medial and lateral femoral condyles. RESULTS: The maximum change in femoral articular cartilage thickness, measured at the left outer lateral femoral condyle, was 6.94% (P=.006). All other femoral articular cartilage thickness changes were not significant. CONCLUSION: A change in femoral articular cartilage thickness of 6.94% supports our hypothesis that long-distance running does not induce deformational changes greater than that of regular daily activities. This study using ultrasonography supports MRI evidence that knee cartilage tolerates marathon running well.

Abdominal Body Composition Reference Ranges and Association With Chronic Conditions in an Age- and Sex-Stratified Representative Sample of a Geographically Defined American Population.

BACKGROUND: Body composition can be accurately quantified from abdominal computed tomography (CT) exams and is a predictor for the development of aging-related conditions and for mortality. However, reference ranges for CT-derived body composition measures of obesity, sarcopenia, and bone loss have yet to be defined in the general population. METHODS: We identified a population-representative sample of 4 900 persons aged 20 to 89 years who underwent an abdominal CT exam from 2010 to 2020. The sample was constructed using propensity score matching an age and sex stratified sample of persons residing in the 27-county region of Southern Minnesota and Western Wisconsin. The matching included race, ethnicity, education level, region of residence, and the presence of 20 chronic conditions. We used a validated deep learning based algorithm to calculate subcutaneous adipose tissue area, visceral adipose tissue area, skeletal muscle area, skeletal muscle density, vertebral bone area, and vertebral bone density from a CT abdominal section. RESULTS: We report CT-based body composition reference ranges on 4 649 persons representative of our geographic region. Older age was associated with a decrease in skeletal muscle area and density, and an increase in visceral adiposity. All chronic conditions were associated with a statistically significant difference in at least one body composition biomarker. The presence of a chronic condition was generally associated with greater subcutaneous and visceral adiposity, and lower muscle density and vertebrae bone density. CONCLUSIONS: We report reference ranges for CT-based body composition biomarkers in a population-representative cohort of 4 649 persons by age, sex, body mass index, and chronic conditions.

Clinical Applications, Challenges, and Recommendations for Artificial Intelligence in Musculoskeletal and Soft-Tissue Ultrasound: AJR Expert Panel Narrative Review.

Artificial intelligence (AI) is increasingly used in clinical practice for musculoskeletal imaging tasks, such as disease diagnosis and image reconstruction. AI applications in musculoskeletal imaging have focused primarily on radiography, CT, and MRI. Although musculoskeletal ultrasound stands to benefit from AI in similar ways, such applications have been relatively underdeveloped. In comparison with other modalities, ultrasound has unique advantages and disadvantages that must be considered in AI algorithm development and clinical translation. Challenges in developing AI for musculoskeletal ultrasound involve both clinical aspects of image acquisition and practical limitations in image processing and annotation. Solutions from other radiology subspecialties (e.g., crowdsourced annotations coordinated by professional societies), along with use cases (most commonly rotator cuff tendon tears and palpable soft-tissue masses), can be applied to musculoskeletal ultrasound to help develop AI. To facilitate creation of high-quality imaging datasets for AI model development, technologists and radiologists should focus on increasing uniformity in musculoskeletal ultrasound performance and increasing annotations of images for specific anatomic regions. This Expert Panel Narrative Review summarizes available evidence regarding AI's potential utility in musculoskeletal ultrasound and challenges facing its development. Recommendations for future AI advancement and clinical translation in musculoskeletal ultrasound are discussed.

Magnetic Resonance Imaging of the Shoulder: Interpretation of Common Orthopaedic Injuries.

Magnetic resonance imaging (MRI) is frequently obtained to assess for pathology in the setting of shoulder pain and dysfunction. MRI of the shoulder provides diagnostic information that helps optimize patient management and surgical planning. Both general and subspecialized orthopaedic surgeons routinely order and review shoulder MRIs in practice. Therefore, familiarity with the MRI appearance of common shoulder pathologies is important. This document reviews the most common shoulder pathologies using a standardized MRI interpretative approach. Instructional videos demonstrating a musculoskeletal radiologist interpreting normal and abnormal shoulder MRIs are also provided.

ACR Appropriateness Criteria® Soft Tissue Masses: 2022 Update.

Imaging should be performed in patients with a suspected soft tissue mass that cannot be clinically confirmed as benign. Imaging provides essential information necessary for diagnosis, local staging, and biopsy planning. Although the modalities available for imaging of musculoskeletal masses have undergone progressive technological advancements in recent years, their overall purpose in the setting of a soft tissue mass remains unchanged. This document identifies the most common clinical scenarios related to soft tissue masses and the most appropriate imaging for their assessment on the basis of the current literature. It also provides general guidance for those scenarios that are not specifically addressed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Preference Signaling for the Diagnostic Radiology Match: A Single Institution Experience.

The Association of American Medical Colleges announced the addition of preference signaling to the 2022-2023 residency match cycle for Diagnostic and Interventional Radiology. This new offering provided applicants the option to indicate their specific interest in up to 6 residency programs during initial application submission. Our institutional diagnostic radiology residency program received a total of 1294 applications. One hundred and eight applicants signaled the program. Interview invitations were sent to 104 applicants, 23 of which signaled the program. Out of the top 10 ranked applicants, 6 applicants signaled the program. Out of the 5 matched applicants, 80% used the program signal, and 100% did the geographic preference. Opting to signal programs during the initial application submission may be beneficial for both the applicants and the programs in finding the optimal match.

Direct anterior approach associated with lower dislocation risk after primary total hip arthroplasty in patients with prior lumbar spine fusion.

BACKGROUND: While there has been much interest in the increased dislocation rate in total hip arthroplasty (THA) patients with a lumbar spine fusion (LSF), there is minimal literature comparing the risk based on surgical approach. The purpose of this study was to determine if a direct anterior (DA) approach was protective against dislocation when compared to the anterolateral and posterior approaches in this high-risk patient population. METHODS: A retrospective review was performed of 6554 THAs performed at our institution from January 2011 to May 2021. 294 (4.5%) patients had a prior LSF and were included in the analysis. The surgical approach, timing of LSF in relation to THA, vertebral levels fused, timing of THA dislocation, and the need for revision surgery were recorded for statistical analysis. RESULTS: In total, 39.7.3% of patients underwent a DA approach (n = 117), 25.9% underwent an anterolateral approach (n = 76), and 34.3% underwent a posterior approach (n = 101). There was no difference in number of vertebral levels fused between groups (mean 2.5, all p > 0.05). There was a total of 13 (4.4%) THA dislocation events, with an average time from surgery to dislocation of 5.6 months (0.3-30.5 months). There were fewer dislocations in the DA cohort (0.9%) in comparison to both the anterolateral (6.6%, p = 0.036) and posterior groups (6.9%, p = 0.026). CONCLUSIONS: The DA approach demonstrated a significantly lower THA dislocation rate compared to both the anterolateral and posterior approaches in patients with a concomitant LSF.

Is Heterotopic Ossification Associated With Surgical Approach in Total Hip Arthroplasty?

BACKGROUND: Although risk factors for heterotopic ossification (HO) have been defined, the effect from surgical approach is not fully understood. The primary objective of our study was to evaluate the effect that surgical approach has on the risk for developing severe HO after total hip arthroplasty (THA) and compare this with other known risk factors. We hypothesized that there would be no difference in HO formation based on the surgical approach. METHODS: We retrospectively reviewed all patients who underwent primary THA at our hospital between March 2011 and March 2021. Patients with HO documented in the radiology reports were cross-referenced with our THA data set and manually reviewed to determine Brooker classification. Patient demographics, medical comorbidities, surgical details, and medication information were collected from the electronic medical record and compared. RESULTS: Of 3,427 patients who underwent THA, 677 (19.8%) developed HO postoperatively. A multivariable analysis confirmed that surgical approach was independently associated with increased odds for HO development. The anterolateral (odds ratio [OR], 3.43; P < 0.001) and posterior (OR, 2.24; P < 0.001) approaches had increased odds for developing HO compared with the direct anterior approach. However, only the anterolateral approach (OR, 1.85; P = 0.033) demonstrated an increased association with the development of severe HO (Brooker 3, 4) postoperatively. CONCLUSION: Although the use of the direct anterior approach had the lowest overall OR for developing HO after THA, this is likely only clinically notable when compared with the anterolateral approach. LEVEL OF EVIDENCE: III.

A case report of 2 distinct primary sarcomas arising in an extremity in rapid succession.

A 59-year-old male presented with a primary synovial sarcoma around his knee. Two months after resection, he presented with a new, rapidly-growing mass in the ipsilateral proximal thigh. A biopsy of the new mass demonstrated a pleomorphic liposarcoma, distinct from the prior synovial sarcoma. He underwent neoadjuvant radiation, followed by wide resection. He is now undergoing surveillance for recurrence. While 2 distinct primary sarcomas developing in rapid succession is rare, this case emphasizes the need for a complete work-up, including obtaining a tissue diagnosis for suspected recurrent lesions as this may alter treatment and follow-up recommendations.

A Pilot Study of Intralesional Injection of Triamcinolone Acetonide for Desmoid Tumors: Two-Year Outcomes.

PURPOSE: The purpose of this pilot study was to examine the clinical efficacy and safety of serial triamcinolone injections for the treatment of desmoid tumors. PATIENTS AND METHODS: Nine patients were enrolled into this prospective study and underwent three serial ultrasound-guided triamcinolone injections (120 mg) at 6-week intervals. MRI was compared at baseline and every 6 months, out to 24 months. Safety and tolerability were assessed by clinical evaluation and questionnaires, including the 12-item short form survey (SF-12), visual analog scale (VAS), and desmoid patient-reported outcome (PRO) tool. RESULTS: At 24 months, 8 (88.9%) patients demonstrated a reduction in the volume of their tumor while 1 (11.1%) enlarged. Median tumor volume change was -26.9% (-81.1% to 34.6%; P = 0.055) All 9 tumors remained stable based on World Health Organization criteria, whereas 2 (22.2%) demonstrated partial response based on RECIST. There was a significant decrease in the tumor:muscle postcontrast mean signal intensity ratio at 6 months (P = 0.008) and 24 months (P = 0.004). There was a similar decrease in the tumor:muscle T2 mean signal intensity ratio at 24 months (P = 0.02). We found no difference in the SF-12 and VAS scores, but there were significant improvements in the desmoid PRO. CONCLUSIONS: Treatment of desmoid tumors with serial triamcinolone injections appears safe and well tolerated by patients, with a 22% partial response based on RECIST. Further research is needed to confirm our results and determine factors predictive of response.

Creating High Fidelity Synthetic Pelvis Radiographs Using Generative Adversarial Networks: Unlocking the Potential of Deep Learning Models Without Patient Privacy Concerns.

BACKGROUND: In this work, we applied and validated an artificial intelligence technique known as generative adversarial networks (GANs) to create large volumes of high-fidelity synthetic anteroposterior (AP) pelvis radiographs that can enable deep learning (DL)-based image analyses, while ensuring patient privacy. METHODS: AP pelvis radiographs with native hips were gathered from an institutional registry between 1998 and 2018. The data was used to train a model to create 512 × 512 pixel synthetic AP pelvis images. The network was trained on 25 million images produced through augmentation. A set of 100 random images (50/50 real/synthetic) was evaluated by 3 orthopaedic surgeons and 2 radiologists to discern real versus synthetic images. Two models (joint localization and segmentation) were trained using synthetic images and tested on real images. RESULTS: The final model was trained on 37,640 real radiographs (16,782 patients). In a computer assessment of image fidelity, the final model achieved an "excellent" rating. In a blinded review of paired images (1 real, 1 synthetic), orthopaedic surgeon reviewers were unable to correctly identify which image was synthetic (accuracy = 55%, Kappa = 0.11), highlighting synthetic image fidelity. The synthetic and real images showed equivalent performance when they were assessed by established DL models. CONCLUSION: This work shows the ability to use a DL technique to generate a large volume of high-fidelity synthetic pelvis images not discernible from real imaging by computers or experts. These images can be used for cross-institutional sharing and model pretraining, further advancing the performance of DL models without risk to patient data safety. LEVEL OF EVIDENCE: Level III.

Radiologists should use the hip-knee-ankle angle rather than the mechanical axis deviation to describe knee alignment.

OBJECTIVE: Preoperative and postoperative coronal knee alignment is an important predictor of total knee arthroplasty (TKA) failure. Radiologists often report the mechanical axis deviation (MAD) rather than hip-knee-ankle angle (HKAA) to describe coronal knee alignment. The aim of this study is to evaluate (i) how well the MAD predicts the HKAA; (ii) if patient height and sex affect the performance of the MAD; and (iii) if the MAD could be measured faster than the HKAA. MATERIALS AND METHODS: Two hundred patients undergoing hip-to-ankle radiographs for TKA planning were retrospectively reviewed. The MAD and HKAA were measured using previously published methods by the Visage picture archiving and communication systems (PACS) tools. Receiver operator characteristic (ROC) curves were used to evaluate the performance of the MAD to predict HKAA by gender and height. The performance of a linear model was used to predict HKAA from MAD in a prospectively collected cohort of 40 patients. Paired t tests were used for the comparison of time measurement in MAD and HKAA in this cohort. RESULTS: MAD strongly correlated with HKAA (r = 0.99, p < 0.001); however, the performance of MAD differed by height (p = 0.005) and sex (p < 0.001). There was no significant difference in the time taken to measure HKAA versus MAD (p > 0.05). CONCLUSION: HKAA should be used instead of the MAD because it is more clinically relevant and takes the same amount of time to be measured.

Comparison of Cortical Bone Fracture Patterns Under Compression Loading Using Finite Element-Discrete Element Numerical Modeling Approach and Destructive Testing.

Finite element analysis may not be the only method by which bone fracture initiation and propagation may be analyzed. This study compares fracture patterns generated from compression testing of bone to fracture patterns generated using a combination of both the finite element method (FEM) and discrete element method (DEM) as defined by the finite discrete element method (FDEM). Before testing, a three-dimensional bone model was developed using CT. Force and displacement data were collected during testing. The tested specimen was reimaged using CT. The solid model was discretized and material properties adjusted such that finite element-discrete element macro behavior matched the force-displacement data. A qualitative comparison of the fracture patterns demonstrates that FDEM can successfully be used to simulate and predict fracturing in bone, with this study representing the first time this has been done and reported.

ACR Appropriateness Criteria® Malignant or Aggressive Primary Musculoskeletal Tumor-Staging and Surveillance: 2022 Update.

Malignant or aggressive primary musculoskeletal tumors are rare and encompass a wide variety of bone and soft tissue tumors. Given the most common site for metastasis from these primary musculoskeletal tumors is to the lung, chest imaging is integral in both staging and surveillance. Extrapulmonary metastases are rarely encountered with only a few exceptions. Following primary tumor resection, surveillance of the primary tumor site is generally recommended. Local surveillance imaging recommendations differ between primary tumors of bone origin versus soft tissue origin. This document consolidates the current evidence and expert opinion for the imaging staging and surveillance of these tumors into five clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot): 2022 Update.

Musculoskeletal infections involve bones, joints, and soft tissues. These infections are a common clinical scenario in both outpatient and emergent settings. Although radiography provides baseline findings, a multimodality approach is often implemented to provide more detailed information on the extent of infection involvement and complications. MRI with intravenous contrast is excellent for the evaluation of musculoskeletal infections and is the most sensitive for diagnosing osteomyelitis. MRI, CT, and ultrasound can be useful for joint and soft tissue infections. When MRI or CT is contraindicated, bone scans and the appropriate utilization of other nuclear medicine scans can be implemented for aiding in the diagnostic imaging of infection, especially with metal hardware and arthroplasty artifacts on MRI and CT. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Anomalous Course of the Brachial Plexus Identified During Ultrasound-Guided Brachial Plexus Nerve Block.

Knowledge of brachial plexus anatomy is essential when performing upper-extremity regional anaesthesia. Anomalous brachial plexus anatomy has been reported in up to 35% of patients. Variants include anomalous course of the roots anterior to, or within, the scalene musculature and abnormal separation of the cords around the subclavian artery. These anomalies have been detected with ultrasound, a valuable tool for delineating anatomy and providing imaging guidance during regional anaesthesia. We report a previously undescribed course of the brachial plexus relative to the subclavian artery within the supraclavicular fossa identified by ultrasound prior to peripheral nerve blockade.