Skeletal Radiol DOI 10.1007/s00256-016-2474-8

MEETING REPORT

Society of Skeletal Radiology 2016 Annual Meeting Summary Michael G. Fox 1 & Laura W. Bancroft 2

# ISS 2016

Abstract Peer-reviewed abstracts presented at the 2016 Society of Skeletal Radiology (SSR) Annual Meeting were reviewed following oral presentation. Topics felt to be of potential interest to musculoskeletal (MSK) investigators and practicing clinicians are highlighted in this compilation and analysis of the meeting. New concepts regarding MSK imaging and intervention, MSK protocols and techniques, radiology education and quality improvement are included. ePoster highlights are also presented.

Keywords Musculoskeletal imaging . Medical society meetings . Education . Research . Quality improvement

Introduction The Society of Skeletal Radiology (SSR) held its 2016 annual meeting at The Roosevelt, a Waldorf Astoria Hotel in New Orleans, LA, from 13–16 March 2016. The meeting was attended by 302 society members and 47 musculoskeletal (MSK) radiology fellows.

* Michael G. Fox [email protected]

1

Department of Radiology and Medical Imaging, University of Virginia, 1218 Lee Street, Box 800170, Charlottesville, VA 22908, USA

2

Department of Radiology, Florida Hospital, 601 E. Rollins, Orlando, FL 32803, USA

Scientific program A record 141 abstracts were submitted by SSR members for consideration, reflecting their active clinical research. From these submissions, the program committee selected 56 abstracts (up from 52 in the previous year) for oral presentation and inclusion in the scientific program. Abstracts were presented by major topic, including General Imaging, Spine, Lower Extremity, Tumor, Ankle/Foot, Upper Extremity, Outcomes and Technical. In total, over 20 h of AMA category 1 continuing medical education credits were available. A listing of the scientific program is available at https://docs.omnibooksonline. com/assets/SSR13903/60350/SSR_39th_Meeting_web. pdf. In addition, 49 electronic scientific and educational posters (ePosters) were available for review at the meeting. These ePoster presentations are accessible to SSR members at http://ssrannualmeeting.conferencespot.org/. In total, over 50 separate institutions were represented in the program. The SSR hosted the 5th annual hands-on MSK ultrasound (US) tutorial session, which was once again attended by a capacity group of 50 radiologists. The focus of the US session was imaging of the wrist and hand. For the 11th consecutive year, 3 h of self-assessment modules (SAMs) was offered and attended by a majority of the meeting participants. While the general meeting abstracts were presented by subject matter as listed above, the meeting highlights are more easily summarized by themes or emphasis, as noted below. The vast majority of the presentations were related to shoulder, tumor, hip and knee imaging as well as interventional procedures. Excellent presentations regarding imaging of other joints and the spine were also presented.

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Summary of the meeting highlights Shoulder In a study evaluating 160 shoulder MRIs, New York University (NYU) radiologists reported that the bipolar growth plate of the coracoid process may close as early as age 11 and that 86 % closed between the ages of 15–18. They emphasized that when “fluid” signal was present within the bone marrow or surrounding soft tissues or if there was growth plate widening or irregularity, a stress-related growth plate injury of the coracoid should be considered [1]. NYU radiologists also found that the central glenoid bare area was more commonly present in children aged 10–15 (20 %) compared to older children (5 %) (p = 0.007) [2]. NYU radiologists also concluded that the MR imaging findings of coracohumeral ligament and axillary recess thickening and subcoracoid fat infiltration were only 33 % sensitive, 84 % specific and 81 % accurate in diagnosing adhesive capsulitis [3].

iliopsoas impingement (IPI) and found that tendon diameter or number did not impact postoperative outcomes with similar improvement in pain and function for either central or peripheral release. However, they did note an association of worse postoperative outcomes when lateral dipping of the tendon at the acetabular rim, iliopsoas tendonopathy or bursitis and cartilage degeneration were present preoperatively [7]. Knee

Radiologists from Thomas Jefferson University (Jefferson) evaluated 144 baseball players with medial elbow pain using both stress ultrasound and MR arthrography to determine whether utilizing both imaging modalities was more accurate in diagnosing the etiology of medial elbow pain compared to each modality alone. The authors found that for ulnar collateral ligament tears and ulnar neuritis, the combined interpretation increased the accuracy to 98 % (p ≤ 0.001). However, for myotendinous and osteochondral injuries, the addition of ultrasound did not increase the accuracy of MR arthrography alone [4]. Jefferson radiologists also reported the variable appearance of the carpal boss including the frequency of coalition between the third metacarpal and an os styloideum as well as the extensor carpi radialis brevis (ECRB) insertion site. In 48 patients with dorsal wrist pain, they found that 75 % (n = 36) had bone marrow edema within an unfused or partially fused os styloideum with at least partial insertion of the ECRB at that location [5].

Radiologists from NYU evaluated 50 patients with arthroscopic correlation to determine whether the sensitivity, specificity and accuracy for detecting meniscus or ACL tears using an optimized 3D SPACE sequence with SPARSE-SENSE acceleration were equivalent to conventional 2D proton density and T2 fat-suppressed 3-T knee MR imaging. Two radiologists independently reviewing the images reported similar findings with both protocols, and the authors concluded that accelerated 3D imaging reduces the scan time by over 50 % and has the potential to replace conventional 2D knee imaging [8]. University of Wisconsin radiologists evaluated 141 patients with prior meniscal surgery and arthroscopic correlation to determine the characteristics of retorn menisci in this population. On the T2 sequence, menisci with a high or intermediate-high line extending to the articular surface were torn, menisci without a line extending to the articular surface were intact, and menisci with an intermediate signal line extending to the articular surface of the meniscus were torn in nearly 70 % of cases. In the latter group, meniscal tears were correlated with an irregular meniscal contour, abnormal linear signal involving either five or more slices or extending through over 75 % of the meniscus and displaced meniscal fragments [9]. A four-level grading system for subchondral insufficiency fracture of the knee (SINK) was proposed by Jefferson radiologists with level 1 classified as bone marrow edema without fracture and level 4 representing subchondral fracture with early osteonecrosis. The higher grades of SINK progressed in over 50 % of patients and were associated with meniscal root tears with extrusion, chondrosis, increased age and increased weight. In contrast, lower grades of SINK resolved or improved in over 75 % of patients [10].

Hip

Ankle/foot

University of Colorado radiologists reported on the expected 1- and 5-month post primary arthroscopic labral repair appearance in 25 patients using 3-T MRI. Nearly 80 % of the patients had globular labral signal or signal undermining the acetabular/labral interface with over 90 % having linear signal extending to the labral surface. These findings were noted to decrease in incidence at 5 months [6]. University of Wisconsin radiologists evaluated over 80 patients who had either central or peripheral iliopsoas tendon arthroscopic release for

Radiologists from the University of Arizona reported that ultrasound tension elastography (UTE) was useful in differentiating healthy from abnormal posterior tibialis tendons (p < 0.01). The preliminary study involving fewer than 20 patients suggested that UTE had the potential to better direct patient care to either surgery or rehabilitation [11]. NYU radiologists found that tarsal tunnel pathology was common in patients with medial hindfoot coalitions with the flexor hallucis abnormal in >40 %, the flexor digitorum longus in

Elbow/wrist

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>30 %, posterior tibial nerve and branches in >25 % [12]. Plantar talar head contusions and osteochondral fractures were evaluated on MRI in over 40 patients by radiologists from Einstein Medical Center, and a high association of transverse tarsal joint complex injuries was found. These associated injuries included: anterior process of the calcaneus [odds ratio (OR) >12], plantar aspect of the spring ligament (OR > 9), cuboid (OR > 6) and extensor digitorum brevis (OR > 5) [13]. Penn State University radiologists retrospectively categorized 44 patients with diabetic foot ulcers into having either osteitis (increased T2 but normal T1 signal) or osteomyelitis (increased T2 with corresponding decreased T1 signal) utilizing MRI. Review of the initial interpretations found great variability in the diagnosis of osteitis with many MRIs interpreted as either “osteitis but unable to exclude early osteomyelitis” or “early osteomyelitis.” The administration of IV antibiotics was higher in osteitis patients reported to have “early osteomyelitis” (50 %) compared to those reported to have “osteitis without osteomyelitis” (17 %); however, MRI progression to osteomyelitis in nearly 60 % of the patients with osteitis occurred within 12 months sugesting that osteitis might preceed osteomyelitis [14].

deep-seated soft tissue mass usually exhibited heterogeneous T2w signal with central necrosis noted in nearly 50 % and peripheral nodular enhancement in 60 % of cases. Of note, calcification was present more often (33 %) than previously reported [18]. Interventional Radiologists from the University of Wisconsin retrospectively reviewed over 100 consecutive Baker’s cyst aspirations followed by steroid injections. Patients with either little to no radiographic evidence of knee arthritis and/or complete cyst aspiration experienced longer relief (∼3 months) of symptoms compared to other patients (∼2 months pain relief) [19]. In a prospective study, University of Virginia radiologists reported a significant reduction in pain and improvement in function in 25 patients evaluated 10 and 41 weeks following ultrasound-guided percutaneous tenotomy (TENEX). However, they found no correlation among age, gender, tendinopathy grade by ultrasound and needle cutting time and improvement in symptoms [20].

Tumor

Miscellaneous imaging topics

The incidence of osseous pseudoprogression (OPP), defined as transient growth in abnormal signal centered at the lesion with subsequent decrease in abnormality on follow-up MRI not attributable to chemotherapy, was evaluated by M.D. Anderson radiologists in 36 patients following spine stereotactic radiosurgery. The authors found OPP present in 14 % of the patients and an association with single-fraction therapy. The mean time to peak enlargement was ∼14 weeks, and most lesions returned to baseline between 6 and 12 months [15]. Radiologists from NYU evaluated whole-body hybrid PETMRI in 15 patients to directly compare the individual utility of fluorine-18 labeled fluorodeoxyglucose (FDG) PET, sodium fluoride (NaF) PET and diffusion-weighted imaging (DWI). NaF PET was the most sensitive (100 %) and DWI the most specific (100 %) in differentiating malignant from benign osseous lesions [16]. Radiologists from the American Institute for Radiologic Pathology (AIRP) evaluated 20 patients with chondroblastic osteosarcoma and found that a soft tissue mass, which was the predominant location for the chondroid elements, was present in all cases, the chondroid elements were identifiable on MRI by increased T2w signal in 90 % of cases, and both osteoid mineralization and thin septal enhancement were present in >75 % of cases. The authors concluded that biopsy of both the osteoid- and chondroid-appearing elements is required to decrease the chance of misdiagnosing the chondroblastic osteosarcoma as chondrosarcoma [17]. AIRP radiologists also described the imaging characteristics of lowgrade fibromyxoid sarcoma (Evans tumor) in 12 patients. This

Radiologists from the Hospital for Special Surgery, studying the utility of high-resolution ultrasound and MRI in evaluating peripheral nerves, found both modalities to correlate in >50 % of the 99 patients evaluated. However, in ∼25 % of the cases, MRI demonstrated findings not evident on US, and in ∼15 % of the cases US demonstrated more findings compared to MRI, suggesting that the modalities are complimentary to each other in some cases [21]. Quality improvement University of Maryland radiologists evaluated the utility of MRI patient questionnaires compared to ordering provider clinical history. They found that in >20 % of cases the patient questionnaire was more helpful in providing information useful to interpreting the MRI and in 15 % of cases the reverse was true. In addition, the history provided by the ordering clinician was inadequate for billing purposes in a similar percentage of patients. [22]. Finally, a survey of SSR member attitudes regarding the handling of scout and other “nondiagnostic” MRI and CT sequences was presented by the President of the Society. He reported that over 13 % of respondents excluded all nondiagnostic sequences (to include scout images) from PACS and another 30 % selective filtered the images sent to PACS. Moreover, even when the “nondiagnostic” images were sent to PACS, only ∼50 % of Society respondents actually viewed those images [23].

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Award-winning presentations While many paper presentations were noteworthy, two of the papers were selected for presentation at upcoming international meetings. The paper selected for presentation at the 2016 Radiological Society of North America meeting in Chicago, IL, was entitled “A 5-Minute Shoulder MRI: Is It Good Enough?” presented by a group from the Cleveland Clinic. The authors found that using the “5-min” shoulder MRI protocol that utilized parallel imaging was clinically interchangeable for detecting rotator cuff, labral and biceps pathology compared to the standard shoulder MRI protocol that required an additional ∼9 min [24]. The paper selected for presentation at the 2016 International Skeletal Society meeting in Paris, France, was entitled “Radiculopathy Following Vertebral Body Compression Fracture: Is There a Role for Percutaneous Cement Augmentation?” presented by authors from the University of Colorado. The authors found that in patients with vertebral body fractures treated with either vertebroplasty or kyphoplasty, those with concordant radiculopathy had statistically greater improvement in symptoms compared to those without radiculopathy [25]. The Patrick T. Liu Innovation in Research Award was presented to Robert Boutin from the University of California at Davis for a presentation entitled “CT of Hip Fracture Patients: Can Muscle Size and Attenuation Predict Clinical Outcome?” [26].

Scientific Poster was won by Barrett Luce from the University of Virginia for the poster entitled “Assessment of Femoral Trochlear Morphology on Cross Sectional Imaging: Comparing the Dejour Classification and Quantitative Measurements in Patients Later Treated with Deepening Trochleoplasty” [32]. Summary A record 56 scientific papers covering a wide range of MSK topics with new information related to imaging findings, imaging techniques and interventional procedures were presented. A large number of ePosters were again available for review on large screen monitors, significantly adding to the information available to the meeting participants. Two well-received afternoon SAM focus sessions were again offered, as was a hands-on MSK US tutorial specific to imaging the wrist and hand, which was attended by a capacity crowd. The 40th annual SSR meeting will be held at the Bacara Resort and Spa in Santa Barbara, CA, from 19–22 March 2017.

References 1.

Young investigator awards Four young investigator awards were selected this year. The awards went to the following scientific presentations: “Quantitative CT Density Evaluation of Osseous Metastases Following Chemotherapy” by Connie Chang of Massachusetts General Hospital [27]; “Utility of 3D Print Models for Pre-operative Planning in Femoral Acetabular Impingement” by Tony Wong from Columbia-Presbyterian Medical Center [28], “Imaging Features on Ibalance, New High Tibial Osteomy: What the Radiologist Needs to Know” by Erin Fitzgerald from NYU Medical Center [29]; “Clinical Utility of Shoulder Imaging in the Outpatient Setting: A Pilot Study” by Elisabeth Garwood also from NYU Medical Center [30]. ePosters Once again, ePosters were a prominent part of the educational experience with 49 available for review on multiple widescreen displays for the duration of the 4-day meeting. The ACR Education Center Award for the Best Education Poster was awarded to Usman Anwer from the University of Michigan for the poster entitled “A Sound Approach to Peripheral Neuropathies” [31]. The AIRP Award for Best

FitzGerald E, Rosenberg Z, Rossi I, Roedl J, Pinkney L, Steinbach L, et al. Skeletal maturation and stress injury of the growth plate at the base of the coracoids process: MRI features. Skeletal Radiol. 2016;45:1170–1. 2. Djebbar S, Rosenberg Z, Rossi I, Agten C, FitzGerald E. Imaging features of glenoid bare area in a pediatric population. Skeletal Radiol. 2016;45:1170. 3. FitzGerald E, Alaia M, Babb J, Gyftopoulos S. Accuracy of the MRI diagnosis of adhesive capsulitis in an academic musculoskeletal radiology division. Skeletal Radiol. 2016;45:1169–70. 4. Roedl J, Nevalainen M, Morrison W, Zoga A, Gonzalez F. Combined MR arthrography and ultrasound approach in imaging of medial elbow pain in baseball players. Skeletal Radiol. 2016;45: 1171. 5. Zoga A, Nevalainen M, Sharma P, Roedl J, Morrison W. Horrible bosses: patterns of MRI findings at the carpal boss and the extensor carpi radialis brevis tendon insertion in patients with activity related dorsal hand pain. Skeletal Radiol. 2016;45:1171–2. 6. Mills M, Jesse MK, Strickland C, Lowry P, Mei-Dan O, Lind K. Primary labral repair: evolution of magnetic resonance imaging findings in the postoperative labrum. Skeletal Radiol. 2016;45: 1169. 7. Sheehan S, Blankenbaker D, Yu T. Is there a role of iliopsoas tendon anatomy in determining efficacy of surgical release for central iliopsoas impingement? Skeletal Radiol. 2016;45:1153–4. 8. Recht M, Otazo R, Rybak L, et al. 3D TSE imaging using sparsesense acceleration: comparison with conventional 2D TSE imaging for detection of internal derangement of the knee. Skeletal Radiol. 2016;45:1155. 9. Williams A, Kijowski R, Rosas H. MRI characteristics of torn and untorn post-operative menisci. Skeletal Radiol. 2016;45:1153.

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Gonzalez F, Roedl J, Morrison W, Zoga A. Patterns of disease progression in SINK, the new SONK, by MRI: grading and clinical implications. Skeletal Radiol. 2016;45:1168. Taljanovic M, Latt D, Gao L, Witte R. In vivo ultrasound tension elastography differentiates healthy from diseased posterior tibialis tendons. Skeletal Radiol. 2016;45:1161. FitzGerald E, Petchprapa C, Rosenberg Z, Bencardino J, Rossi I, Ciavarra G. Association of tarsal tunnel disease with medial hindfoot coalitions. Skeletal Radiol. 2016;45:1160–1. Gorbachova T, Wang P, Hu B, Horrow J. Plantar talar head contusions and osteochondral fractures: associated findings on ankle MRI and proposed mechanism of injury. Skeletal Radiol. 2016;45:1160. Duryea D, Bernard S, Gustas C, et al. Correlation with diabetic foot MRI interpretations with treatment and outcomes. Skeletal Radiol. 2016;45:1162. Amini B, Beaman C, Madewell J, et al. Osseous pseudoprogression in vertebral bodies treated with stereotactic radiosurgery: initial description and timecourse. Skeletal Radiol. 2016;45:1153. Beltran L, Ponzo F. Utility of whole body PET-MRI using FDG, NaF and DWI in evaluating metastatic and primary bone malignancies. Skeletal Radiol. 2016;45:1158–9. Senchak L, Suhardja A, Jelinek J, Kransdorf M, Contreras AL. Imaging of chondroblastic osteosarcoma with pathological correlation. Skeletal Radiol. 2016;45:1157. Suhardja A, Murphey M, Jelinek J, Kransdorf M, Contreras AL. Imaging of low-grade fibromyxoid sarcoma (Evans tumor) with pathologic correlation. Skeletal Radiol. 2016;45:1156–7. Lee K, Tresley J, Wilson J. US-guided Baker’s cyst aspiration with corticosteroid injection: a “do not touch” lesion? Skeletal Radiol. 2016;45:1168–9. Matthews D, Deal ND, Fox MG, Nacey N, Pierce J. Tenex ultrasound guided percutaneous tenotomy for the treatment of chronic lateral epicondylitis: early implementation of this emerging therapy. Skeletal Radiol. 2016;45:1166. Deshmukh S, Nwawka O, Endo Y. Peripheral nerve imaging: correlation of high resolution ultrasound and MRI findings. Skeletal Radiol. 2016;45:1149.

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Davis D, Mulligan M, Moszkowicz A, Resnik C. The adequacy of patient history on clinician referrals and questionnaires for musculoskeletal MRI. Skeletal Radiol. 2016;45:1150. 23. Sonin A. Utilization rates of localizer images by musculoskeletal radiologists when interpreting MR and CT studies: a survey and its potential importance. Skeletal Radiol. 2016;45:1149. 24. Subhas N, Benedick A, Obuchowski N, et al. A 5-minute shoulder MRI: is it good enough? Skeletal Radiol. 2016;45:1165. 25. Jesse MK, Gimare D, Lowry P. Radiculopathy following vertebral body compression fracture: is there a role for percutaneous cement augmentation? Skeletal Radiol. 2016;45:1151. 26. Boutin R, Bamrungchart S, Bateni C, Beavers K, Beavers D, Meehan J, et al. CT of hip fracture patients: can muscle size and attenuation predict clinical outcome? Skeletal Radiol. 2016;45: 1167–8. 27. Chang C, Simeone F, Torriani M, Bredella M. Quantitative CT density evaluation of osseous metastases following chemotherapy. Skeletal Radiol. 2016;45:1157–8. 28. Wong T, Lynch S, Popkin C, Kazam J. Utility of 3D print models for pre-operative planning in femoroacetabular impingement. Skeletal Radiol. 2016;45:1163. 29. Fitzgerald E, Alaia M, Burke C, et al. Imaging features of iBalance, new high tibial osteotomy: what the radiologist needs to know. Skeletal Radiol. 2016;45:1154. 30. Gyftopoulos S, Garwood E, Babb J, Horwitz L, Recht M. Clinical utility of shoulder imaging in the outpatient setting: a pilot study. Skeletal Radiol. 2016;45:1170. 31. Anwer U, Yablon CM, Morag YM, Brandon CJ, Fessell DP, Jacobson JA. A sound approach to peripheral neuropathy. http://ssrannualmeeting.conferencespot.org/2015ssr-am-eposter-b1.2999273/2016eposter-1.3000494/poster16sunday-1.3000615 /a057-1.3000643/ap057-1.3000644 32. Luce BN, Boatman D, Diduch D, Fox MG. Assessment of femoral trochlear morphology on cross sectional imaging: Comparing the Dejour classification and quantitative measurements in patients later treated with deepening trochleoplasty. http://ssrannualmeeting. conferencespot.org/2015ssr-am-eposter-b-1.2999273/2016eposter1.3000494/poster16monday-1.3000563/a067-1.3000612/ap0671.3000613