Gary Hollenberg

Contact patterns in the trapeziometacarpal joint: The role of the palmar beak ligament

Twenty-three cadaver forearm specimens were mounted on a Plexiglas acrylic plastic base for study of the trapeziometacarpal joint. Extrinsic and intrinsic motors were loaded to simulate lateral pinch, and pressure-sensitive film was used to record joint contact patterns in various functional positions. The palmar compartment of the trapeziometacarpal joint was the primary contact area during flexion adduction of the thumb ray in lateral pinch. Simulation of dynamic pinch and release produced dorsal enlargement of the contact pattern, suggesting physiologic translation of the metacarpal on the trapezium. Detachment of the palmar beak ligament resulted in dorsal translation of the contact area, producing a pattern similar to that of cartilage degeneration seen in the osteoarthritic joint. End-stage osteoarthritic specimens had a nonfunctional beak ligament and demonstrated a pathologic total contact pattern of joint congruity that was unaffected by further manipulations of the beak ligament. This work defines the contact patterns in the normal and diseased trapeziometacarpal joint and establishes the important influence of the palmar beak ligament on those contact areas.

Stress reactions of the lumbar pars interarticularis: the development of a new MRI classification system.

Study Design. In a retrospective study, multiple examiners reviewed lumbar magnetic resonance imaging scans to develop a new grading system for lumbar pars interarticularis stress reaction and spondylolysis. The resulting system can be used as a mechanism for classifying patients, and as a measurement tool for future studies assessing the outcome efficacy of lumbar magnetic resonance imaging in patients with abnormalities of the pars interarticularis. Objective. To determine the reliability of patient assignment to five different grades of bone stress reaction involving the lumbar pars interarticularis. Summary of Background Data. Injury to the lumbar pars interarticularis (spondylolysis) is reported to be a common cause of low back pain in young patients. High-field-strength magnetic resonance imaging using fat saturation techniques and dedicated coil technology is sensitive in detecting bone stress injuries of the lumbar pars interarticularis, and thus is an excellent method for diagnosis. It also may be useful in prognostic decision making for these patients. A reliable classification system is a fundamental requirement for performing the research assessing the relationship between lumbar MRI findings and prognosis. Methods. For this study, 55 young athletic patients undergoing evaluation for low back pain with suspected stress injury to the lumbar pars interarticularis underwent standardized lumbar magnetic resonance imaging using a 1.5-T scanner. Magnetic resonance images were reviewed by three readers using a new magnetic resonance classification system developed for lumbar spondylolysis. The findings were assessed for both interobserver and intraobserver reliability for five possible combinations in a 5-grade classification system. Results. On magnetic resonance imaging, 42% of the patients demonstrated signal abnormalities of the lumbar pars interarticularis. The intraobserver and interobserver reliability coefficients for assigning the grade of pars interarticularis abnormality ranged, respectively, from 0.766 (95% confidence interval [CI], 0.62–0.91) to 0.906 (95% CI, 0.80–1), and from 0.706 (95% CI, 0.55–0.86) to 1. Conclusions. Magnetic resonance findings of stress reactions and spondylolysis of the lumbar pars interarticularis can be reliably classified into five grades by experienced readers. Further study is needed to determine the role of these findings in the management of young athletic patients with low back pain.

Sonographic appearance of nonoperatively treated Achilles tendon ruptures.

Abstract Objective. This report describes the gray-scale and color Doppler sonographic appearance of healed Achilles tendon ruptures that have been treated nonoperatively. Design and patients. Eleven patients with acute Achilles tendon ruptures were studied with sonography in the acute setting and following nonoperative management of their torn tendon. Results. On sonographic examination, healed tendons treated nonoperatively are characterized by mild residual distortion of the normal fibrillar architecture of the tendon, anterior bulging or irregularity of the healed tendon, and a hypoechoic area about the site of rupture. Less frequent observations include mildly increased color flow and calcification at the rupture site. The previously described findings of acute tears, including hematomas, gaps at the rupture site, hyperemic torn tendon ends, and markedly distorted fibrillar architecture, were seen to have resolved in this series. Conclusion. The Achilles tendon tear treated nonoperatively has a different sonographic appearance from that of a normal or acutely ruptured tendon.

Impact of Gleason Subtype on Prostate Cancer Detection Using Multiparametric Magnetic Resonance Imaging: Correlation with Final Histopathology

Purpose: We determined whether Gleason pattern 4 architecture impacts tumor visibility on multiparametric magnetic resonance imaging and correlates with final histopathology. Materials and Methods: A total of 83 tumor foci were identified in 22 radical prostatectomy specimens from patients with a prior negative biopsy who underwent magnetic resonance/ultrasound fusion biopsy followed by radical prostatectomy from January 2015 to July 2016. A genitourinary pathologist rereviewed tumor foci for Gleason architectural subtype. Each prostate imaging reporting and data system category 3 to 5 lesion on multiparametric magnetic resonance imaging was paired with its corresponding pathological tumor focus. Univariable and multivariable analyses were performed to determine predictors of tumor visibility. Results: Of the 83 tumor foci identified 26 (31%) were visible on multiparametric magnetic resonance imaging, 33 (40%) were Gleason score 3+3 and 50 (60%) were Gleason score 3+4 or greater. Among tumor foci containing Gleason pattern 4, increasing tumor size and noncribriform predominant architecture were the only independent predictors of tumor detection on multivariable analysis (p = 0.002 and p = 0.011, respectively). For tumor foci containing Gleason pattern 4, 0.5 cm or greater, multiparametric magnetic resonance imaging detected 10 of 13 (77%), 5 of 14 (36%) and 9 of 10 (90%) for poorly formed, cribriform and fused architecture, respectively (p = 0.01). The size threshold for the detection of cribriform tumors was higher than that of other architectural patterns. Furthermore, cribriform pattern was identified more frequently on systematic biopsy than on targeted biopsy. Conclusions: Reduced visibility of cribriform pattern on multiparametric magnetic resonance imaging has significant ramifications for prostate cancer detection, surveillance and focal therapy.

A Comprehensive Analysis of Cribriform Morphology on Magnetic Resonance Imaging/Ultrasound Fusion Biopsy Correlated with Radical Prostatectomy Specimens

Purpose Recently a large body of evidence has emerged indicating that cribriform morphology is an aggressive prostate cancer morphological pattern associated with higher cancer specific mortality. In a comprehensive analysis we compared traditional and contemporary prostate biopsy techniques to detect prostate cancer with cribriform morphology with radical prostatectomy serving as the reference standard. Materials and Methods We queried a retrospectively maintained, single institution, multiparametric magnetic resonance imaging database of 1,001 patients to identify 240 who underwent magnetic resonance imaging‐ultrasound fusion targeted biopsy and concurrent systematic biopsy from December 2014 to December 2016. Of the 3,978 biopsy cores obtained 694 positive cores were rereviewed by a genitourinary pathologist for pattern 4 subtype (cribriform, fused and poorly formed glands). Using paired analysis pathological results among 3 biopsy methods (systematic biopsy, targeted biopsy and systematic plus targeted biopsy) were compared. Prostatectomy specimens were also pathologically reviewed. Results Systematic plus targeted biopsy was superior to systematic biopsy alone or targeted biopsy alone to detect cribriform morphology (all p <0.0001). On final histopathology cribriform tumor foci were associated with an increased percent of pattern 4 involvement and extraprostatic extension (p <0.0001 and 0.003, respectively). Only 17.4% of cribriform tumors in pure form were visible on multiparametric magnetic resonance imaging. Based on final histopathology the sensitivity of systematic biopsy, targeted biopsy and systematic plus targeted biopsy for cribriform morphology was 20.7%, 28.6% and 37.1%, respectively. Conclusions Although systematic plus targeted biopsy was the most accurate biopsy method to detect cribriform morphology, biopsy sensitivity and specificity remained poor.

Radiologic consultation: effect on inpatient diagnostic imaging evaluation in a teaching hospital.

RATIONALE AND OBJECTIVES The authors evaluated radiologic consultation affecting resident physician ordering of relatively expensive imaging studies. METHODS Requisitions (n = 180) for expensive imaging studies from three general medicine floors (two consultation floors, one control floor) were prospectively evaluated. Information on the requisitions was classified as appropriate, inappropriate, or undecided if insufficient information was provided. On the consultation floors, but not the control floor, the medical residents were contacted about all studies initially considered inappropriate or undecided before they were performed. RESULTS Nine of 119 requisitions (7.6%) from the consultation floors were considered inappropriate. In three studies (2.5%) the imaging evaluation was modified as the result of the interaction with the radiologist. There was no significant difference in the total number of radiologic studies or percentage of the total that were expensive imaging studies when comparing the consultation floors with the control floor. CONCLUSION Radiologic consultation on expensive imaging studies through routine review of requisitions did not significantly change their use by house staff.

Multiparametric Magnetic Resonance Imaging of Recurrent Prostate Cancer

Multiparametric magnetic resonance (MR) imaging of the prostate combines both morphological and functional MR techniques by utilizing small field of view T1-weighted, T2-weighted, diffusion-weighted imaging, dynamic contrast-enhanced imaging, and MR spectroscopy to accurately detect, localize, and stage primary and recurrent prostate cancer. Localizing the site of recurrence in patients with rising prostate-specific antigen following treatment affects decision making regarding treatment and can be accomplished with multiparametric prostate MR. Several different treatment options are available for prostate cancer including radical prostatectomy, external beam radiation therapy, brachytherapy, androgen deprivation therapy, or a number of focal therapy techniques. The findings of recurrent prostate cancer can be different depending on the treatment the patient has received, and the radiologist must be able to recognize the variety of imaging findings seen with this common disease. This review article will detail the findings of recurrent prostate cancer on multiparametric MR and describe common posttreatment changes which may create challenges to accurate interpretation.

Ultrasound and color Doppler ultrasound of acute and subacute Achilles tendon ruptures

Acute rupture of the Achilles tendon is one of many foot and ankle injuries that may present to the emergency department. Using ultrasound and color Doppler ultrasound, the radiologist can determine which acutely injured patients require operative management and which can be treated nonoperatively. Nonoperative management can be used in those patients with closely apposed tendon ends. This article reviews the use of gray-scale ultrasound in evaluating the appearance of the torn Achilles tendon. The use of color Doppler ultrasound for distinguishing torn tendon ends from hematoma and granulation tissue is discussed.

Imaging of the Spine in Sports Medicine

Much controversy exists surrounding the utility of plain film, computed tomography, magnetic resonance imaging (MRI), and bone scintigraphy in the evaluation of sports-related spine injuries. The articles reviewed here offer several different perspectives. Cervical spine radiography, return-to-play criteria following cervical trauma, lumbar pain and pars injuries, utility of MRI in acute sports injuries, and sports-specific injuries are reviewed. The relationship between bone mineral density and sports activity is also reviewed.

Institutional Learning Curve Associated with Implementation of a Magnetic Resonance/Transrectal Ultrasound Fusion Biopsy Program Using PI-RADS™ Version 2: Factors that Influence Success

Introduction: We assessed the institutional learning curve associated with adopting fusion biopsy using PI‐RADS™ (Prostate Imaging‐Reporting and Data System) Version 2 (v2) to detect clinically significant prostate cancer, defined as Gleason 7 or greater in men with prior negative biopsies, and identified patient and technical factors that predict success in detecting clinically significant prostate cancer. Methods: A total of 113 consecutive patients with at least 1 prior negative biopsy and multiparametric magnetic resonance imaging examination of the prostate with a PI‐RADS 3 or greater index lesion underwent fusion biopsy at a single academic center previously naïve to fusion biopsy technology. Outcomes include detection rates for Gleason 6 cancer, clinically significant prostate cancer and any cancer. Multiple logistic regression with model selection was used to select covariates having significant effects on the outcome. Results: Prostate cancer was identified in 52% of patients with prior negative prostate biopsies. Among the patients diagnosed with prostate cancer 80% had clinically significant cancer. The clinically significant prostate cancer detection rates using fusion biopsy when a PI‐RADS 3, 4 or 5 index lesion was present on multiparametric magnetic resonance imaging were 6%, 46% and 66%, respectively. PI‐RADS v2 score had a predictive accuracy (AUC) of 0.79 for clinically significant prostate cancer detection. Institutional experience over time, magnetic resonance imaging estimated prostate volume and PI‐RADS v2 score were independent predictors of clinically significant prostate cancer using fusion biopsy. Conclusions: Since fusion biopsy is a highly technique driven process, development of internal quality measures to assess the institutional learning curve and the quality of PI‐RADS v2 scoring is critical with the adoption of this technology.