Levon N. Nazarian

Accuracy of MRI, MR Arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: A Meta-Analysis

OBJECTIVE The purpose of this study was to compare the diagnostic accuracy of MRI, MR arthrography, and ultrasound for the diagnosis of rotator cuff tears through a meta-analysis of the studies in the literature. MATERIALS AND METHODS Articles reporting the sensitivities and specificities of MRI, MR arthrography, or ultrasound for the diagnosis of rotator cuff tears were identified. Surgical (open and arthroscopic) reference standard was an inclusion criterion. Summary statistics were generated using pooled data. Scatterplots of the data sets were plotted on a graph of sensitivity versus (1 - specificity). Receiver operating characteristic (ROC) curves were generated. RESULTS Sixty-five articles met the inclusion criteria for this meta-analysis. In diagnosing a full-thickness tear or a partial-thickness rotator cuff tear, MR arthrography is more sensitive and specific than either MRI or ultrasound (p < 0.05). There are no significant differences in either sensitivity or specificity between MRI and ultrasound in the diagnosis of partial- or full-thickness rotator cuff tears (p > 0.05). Summary ROC curves for MR arthrography, MRI, and ultrasound for all tears show the area under the ROC curve is greatest for MR arthrography (0.935), followed by ultrasound (0.889) and then MRI (0.878); however, pairwise comparisons of these curves show no significant differences between MRI and ultrasound (p > 0.05). CONCLUSION MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears. Ultrasound and MRI are comparable in both sensitivity and specificity.

The Top 10 Reasons Musculoskeletal Sonography Is an Important Complementary or Alternative Technique to MRI

OBJECTIVE Worldwide, the use of sonography for the evaluation of the musculoskeletal system has been growing. However, radiologists in North America have been relatively slow to incorporate musculoskeletal sonography into their practices. The purpose of this article is to show the advantages of musculoskeletal sonography. CONCLUSION Musculoskeletal sonography is an important complementary tool to MRI and is essential for radiologists who want to provide patients with state-of-the-art musculoskeletal imaging.

Musculoskeletal imaging: medicare use, costs, and potential for cost substitution.

PURPOSE The current study explores the substitution of ultrasound (US) for magnetic resonance imaging (MRI) of musculoskeletal (MSK) disorders by describing the recent use and costs of MSK imaging in the Medicare population, projecting these trends from 2006 to 2020, and estimating cost-savings involved in substituting MSK US for MSK MRI, when appropriate. METHODS The study used government-published data sets and de-identified Radiology Information System records exempt from institutional review board approval. From 1 years MSK MRI records (n = 3,621), the proportion of cases in which US could be substituted for MRI was estimated. The use rates for 4 modalities of MSK imaging and average costs were determined from government Medicare data sets from 1996 to 2005. Regression analysis was used to project use rates from 2006 to 2020. The effect on costs of substitution was calculated. RESULTS For the Medicare population, although there has been a moderate overall increase (25.7%) in MSK imaging, MSK MRI has increased 353.5% from 1996 to 2005. Projected MSK imaging costs in 2020 are

Sonographically Guided Percutaneous Needle Tenotomy for Treatment of Common Extensor Tendinosis in the Elbow

3.6 billion, of which

A bilateral comparison of posterior capsule thickness and its correlation with glenohumeral range of motion and scapular upward rotation in collegiate baseball players

2.0 billion will be for MRI. A study of 3,621 MSK MRI reports indicates that 45.4% of primary diagnoses and 30.6% of all diagnoses could have been made with MSK US. The substitution of MSK US for MSK MRI, when appropriate, would lead to savings of more than

Sonographically Guided Percutaneous Needle Tenotomy for Treatment of Common Extensor Tendinosis in the Elbow Is a Corticosteroid Necessary

6.9 billion in the period from 2006 to 2020. CONCLUSION MRI MSK use has grown substantially from 1996 to 2005. The substitution of MSK US, when appropriate, would lead to large cost-savings for Medicare.

Reconstruction for Missed or Neglected Achilles Tendon Rupture with V-Y Lengthening and Flexor Hallucis Longus Tendon Transfer through One Incision

Objective. Chronic tendinosis of the common extensor tendon of the lateral elbow can be a difficult problem to treat. We report our experience with sonographically guided percutaneous needle tenotomy to relieve pain and improve function in patients with this condition. Methods. We performed sonographically guided percutaneous needle tenotomy on 58 consecutive patients who had persistent pain and disability resulting from common extensor tendinosis. Under a local anesthetic and sonographic guidance, a needle was advanced into the common extensor tendon, and the tip of the needle was used to repeatedly fenestrate the tendinotic tissue. Calcifications, if present, were mechanically fragmented, and the adjacent bony surface of the apex and face of the epicondyle were abraded. Finally, the fenestrated tendon was infiltrated with a solution containing corticosteroid mixed with bupivacaine. After the procedure, patients were instructed to perform passive stretches and to undergo physical therapy. During a subsequent telephone interview, patients answered questions about their experience, their functioning level, and their perceptions of procedure outcome. Results. Fifty‐five (95%) of 58 patients were contacted by telephone and agreed to participate in the study. Thirty‐five (63.6%) of 55 respondents reported excellent outcomes, 16.4% good, 7.3% fair, and 12.7% poor. The average follow‐up time from the date of the procedure to the date of the interview was 28 months (range, 17–44 months). No adverse events were reported; 85.5% stated that they would refer a friend or close relative for the procedure. Conclusions. Sonographically guided percutaneous needle tenotomy for lateral elbow tendinosis is a safe, effective, and viable alternative for patients in whom all other nonsurgical treatments failed.

Comparing contrast-enhanced ultrasound to immunohistochemical markers of angiogenesis in a human melanoma xenograft model: preliminary results

HYPOTHESIS We hypothesized that posterior capsule thickness (PCT) would be greater on the dominant arm compared to the non-dominant arm. We also hypothesized that PCT would negatively correlate with glenohumeral internal rotation and scapular upward rotation. In addition, PCT would positively correlate with glenohumeral external rotation. However, currently PCT has not been measured nor have correlations been identified to exist with glenohumeral and scapular motion. Therefore, the purpose of the study was to determine if the posterior capsule was hypertrophied on the dominant arm and to identify if relationships exist with glenohumeral internal rotation (IR), external rotation (ER), and scapular upward rotation (SUR). MATERIALS AND METHODS PCT was measured using a 10-MHz transducer. Glenohumeral IR and ER was measured supine using a digital inclinometer. SUR was measure at 0°, 60°, 90°, and 120° of glenohumeral abduction using a modified digital inclinometer. RESULTS PCT was greater on the dominant compared with the nondominant arm (P = .001). A negative correlation was found between PCT and IR (-0.498, P = .0001). A positive correlation was found between PCT and ER (0.450, P = .002) and between PCT and SUR at 60°, 90°, and 120° of glenohumeral abduction (0.388, P = .006; 0.327, P = .023; 0.304, P = .036, respectively). DISCUSSION This in vivo study demonstrated a hypertrophied posterior capsule and its association with GIRD, ER, and SUR. These observations suggest that PCT does occur on the throwing arm of baseball players and is linked with glenohumeral and scapular alterations. CONCLUSIONS This methodology could be used as a noninvasive screening evaluation for overhead athletes to identify those who may be at risk for shoulder injuries due to excessive capsular thickening.

Dramatically Increased Musculoskeletal Ultrasound Utilization From 2000 to 2009, Especially by Podiatrists in Private Offices

Objective. Chronic refractory common extensor tendinosis of the lateral elbow has been shown to respond to sonographically guided percutaneous needle tenotomy (PNT) followed by corticosteroid injection. In this analysis, we attempted to determine whether the corticosteroid is a necessary component of the procedure. Methods. We performed PNT on 57 consecutive patients (age range, 34–61 years) with persistent pain and disability resulting from common extensor tendinosis. Under a local anesthetic and sonographic guidance, a needle was advanced into the tendon, and the tip of the needle was used to fenestrate the tendinotic tissue, break up any calcifications, and abrade the adjacent bone. After the procedure, patients underwent a specified physical therapy protocol. During a subsequent telephone interview, patients answered questions about their symptoms, the level of functioning, and perceptions of the procedure outcome. Results. Of the 52 patients who agreed to participate in the study, 30 (57.7%) reported excellent outcomes, 18 (34.6%) good, 1 (1.9%) fair, and 3 (5.8%) poor. The average follow‐up time from the date of the procedure to the telephone interview was 22 months (range, 7–38 months). No adverse events were reported, and 90% stated that they would refer a friend or close relative for the procedure. Conclusions. Sonographically guided PNT for refractory lateral elbow tendinosis is an effective procedure, and subsequent corticosteroid injection is not necessary.

Outcomes of Chronic Insertional Achilles Tendinosis Using FHL Autograft Through Single Incision

Background: The purpose of this study was to introduce a novel operative technique and to evaluate the clinical outcomes in a cohort of patients with missed or neglected Achilles tendon ruptures. Methods: Fifteen consecutive patients with missed complete Achilles tendon ruptures and 5-cm or larger gaps had reconstruction with V-Y lengthening and flexor hallucis longus tendon transfer through a single incision. The patients were evaluated at an average of 106 weeks after surgery. At the time of followup, all patients were assessed with regard to their self-reported level of satisfaction and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Ankle strength and active range of motion were evaluated using Biodex® (Biodex Medical Systems, Shirley, NY) isokinetic dynamometry. In addition, seven patients were evaluated using diagnostic ultrasound. Results: We found a 7.7 N-m (–22.3%) loss of plantarflexion torque at 60 degrees/sec and a 3.5 N-m (–13.5%) loss of plantarflexion torque at 120 degrees/sec, as well as a 5 degrees loss of active range of motion. AOFAS scores were all good to excellent, with an average score of 94.1 of 100. All patients were satisfied with their outcomes (rated good or very good). Excellent exposure of the Achilles tendon repair was obtained with ultrasound. Conclusions: For patients with missed or neglected Achilles tendon rupture with a rupture gap of at least 5 cm, operative repair using V-Y lengthening and flexor hallucis longus tendon transfer through a single incision technique achieved a high percentage of satisfactory results.