Publications by authors named "Felix M Gonzalez"

26 Publications

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Correction to: Shear wave elastography assessment and comparison study of the Achilles tendons in optimally conditioned asymptomatic young collegiate athletes.

Skeletal Radiol 2021 May 20. Epub 2021 May 20.

Department of Radiology and Imaging Sciences, Emory School of Medicine, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA.

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http://dx.doi.org/10.1007/s00256-021-03818-4DOI Listing
May 2021

Shear wave elastography assessment and comparison study of the Achilles tendons in optimally conditioned asymptomatic young collegiate athletes.

Skeletal Radiol 2021 May 8. Epub 2021 May 8.

Department of Radiology and Imaging Sciences, Emory School of Medicine, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA.

Objective: To assess the functional parameters of the Achilles tendons among asymptomatic college level athletes using shear wave elastography (SWE) and to describe the relationship to athlete demographics and anthropometric lower extremity measurements.

Material And Methods: Sixty-five athletes were included in this IRB-approved study. SWE measurements were made on two tendon positions (neutral state and active maximum dorsiflexion) with two different probe orientations (longitudinal and transverse). Associations were assessed with BMI, tibial/foot length, type of sports, and resting/maximal dorsiflexion-plantar flexion angles.

Results: Thirty-five (53.8%) males and 30 (46.2%) females with an overall mean age of 20.9 years (± 2.8), mean height of 176 cm (± 0.11), and mean weight of 74.1 kg (± 12) were studied. In the neutral state, the mean wave velocity of 7.5 m sec and the mean elastic modulus of 176.8 kPa were recorded. In active maximum dorsiflexion, the mean velocity was 8.3 m sec and mean elastic modulus was 199 kPa. On the transverse view, the mean velocity and elastic measurements were significantly lower (p = 0.0001). No significant differences in SWE parameters were seen between male and female athletes regardless of probe orientation (p < 0.05) with SWE values being higher in the running group vs non-running group (p < 0.05). In neutral state, longitudinal SWE measurements correlated with the tibia-foot length whereas transverse measurements correlated with the tendon diameter and ankle resting angle (ARA) (p < 0.005).

Conclusion: SWE can distinguish functional differences in Achilles tendon stiffness between athletes engaged in running-intensive sports compared with other athletes.
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http://dx.doi.org/10.1007/s00256-021-03798-5DOI Listing
May 2021

The Global Reading Room: Intraarticular Steroid Injection of the Knee.

AJR Am J Roentgenol 2021 04 28. Epub 2021 Apr 28.

Radiology Department, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland.

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http://dx.doi.org/10.2214/AJR.21.26084DOI Listing
April 2021

Subchondral insufficiency fracture of the knee: unicompartmental correlation to meniscal pathology and degree of chondrosis by MRI.

Skeletal Radiol 2021 Apr 17. Epub 2021 Apr 17.

Department of Radiology and Imaging Sciences Section of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA.

Objective: To assess the relationship between low- and high-grade subchondral insufficiency fracture of the knee (SIFK) and meniscal tear/type/location, severity of meniscal extrusion, grade of chondrosis, and extent of surrounding edema-like marrow signal intensity.

Materials And Methods: Our retrospective study included 219 patients with knee pain and SIFK seen on MRI. SIFK lesions were categorized from grade 1 to 4 with a low grade (1 and 2) vs high grade (3 and 4) distinction. Associations between SIFK grade, location, lesion dimensions, edema-like marrow signal intensity, incidence of meniscal tears/type/location, and chondrosis (grade 0 to grade 4), as well as patients' age and weight, were assessed.

Results: Our analysis consisted of 115 males and 104 females with 17% of the patients showing grade 1 SIFK, 59% grade 2, 16% grade 3, and 8% grade 4. No chondrosis or low-grade chondrosis was mostly present in patients with low-grade SIFK (68.9%), whereas high-grade chondrosis was mostly present in patients with high-grade SIFK lesions (65.4%) (p < 0.01). Further sub-analysis demonstrated that high-grade SIFK was associated with high-grade chondrosis in the same compartment (p < 0.01) but not in the adjacent compartment. There was a significant difference in the extent of edema-like marrow signal intensity between the two groups, with high-grade SIFK more frequently demonstrating severe edema-like marrow signal intensity compared to low-grade SIFK (p < 0.01).

Conclusion: High-grade SIFK lesions are associated with unicompartmental high-grade chondrosis.
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http://dx.doi.org/10.1007/s00256-021-03777-wDOI Listing
April 2021

Multi-component relaxation modelling in human Achilles tendon: Quantifying chemical shift information in ultra-short echo time imaging.

Magn Reson Med 2021 07 15;86(1):415-428. Epub 2021 Feb 15.

Department of Radiology & Imaging Sciences, School of Medicine, Emory University, Atlanta, Georgia, USA.

Purpose: To examine multi-component relaxation modelling for quantification of on- and off-resonance relaxation signals in multi-echo ultra-short echo time (UTE) data of human Achilles tendon (AT) and compare bias and dispersion errors of model parameters to that of the bi-component model.

Theory And Methods: Multi-component modelling is demonstrated for quantitative multi-echo UTE analysis of AT and supported using a novel method for determining number of MR-visible off-resonance components, UTE data from six healthy volunteers, and analysis of proton NMR measurements from ex vivo bovine AT. Cramer-Rao lower bound expressions are presented for multi- and bi-component models and parameter estimate variances are compared. Bias error in bi-component estimates is characterized numerically.

Results: Two off-resonance components were consistently detected in all six volunteers and in bovine AT data. Multi-component model exhibited superior quality of fit, with a marginal increase in estimate variance, when compared to the bi-component model. Bi-component estimates exhibited notable bias particularly in in the presence of off-resonance components.

Conclusion: Multi-component modelling more reliably quantifies tendon matrix water components while also providing quantitation of additional non-water matrix constituents. Further work is needed to interpret the origin of the observed off-resonance signals with preliminary assignments made to chemical groups in lipids and proteoglycans.
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http://dx.doi.org/10.1002/mrm.28686DOI Listing
July 2021

Clinicoradiographic predictors of percutaneous bone biopsy results among patients with suspected thoracolumbar spine infection.

Skeletal Radiol 2021 Feb 12. Epub 2021 Feb 12.

Department of Radiology and Imaging Sciences Section of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite, 4009, 30329, Atlanta, GA, USA.

Background: Image-guided percutaneous thoracolumbar spine biopsy is frequently performed in the setting of suspected septic facet arthritis or discitis osteomyelitis (DOM). There are limited data regarding factors associated with a positive biopsy result among these patients.

Materials And Methods: Patients with suspected DOM who underwent spine biopsy were identified. Samples yielding a positive culture and/or histopathology suggestive of acute osteomyelitis were considered positive. The associations between selected medical comorbidities, laboratory values, pre-biopsy antibiotic administration, imaging findings and biopsy results were investigated.

Results: 121 patients underwent percutaneous biopsy with 35.5% yielding positive results. Biopsy results showed no correlation with comorbidities. The only laboratory value that correlated with a positive biopsy yield was blood culture positivity (p = 0.03). The imaging findings that correlated with a positive biopsy yield were the presence of a paraspinal fluid collection or epidural abscess (p = 0.003 and 0.018, respectively). Sampling paraspinal fluid collections, when present, resulted in a higher rate of a positive biopsy yield compared to sampling of bone or disc (p = 0.006). Patients who received antibiotics had a higher rate of a positive biopsy yield (p = 0.014). In those with positive blood cultures, biopsy yielded the same antimicrobial susceptibility profile in 13/14 cases.

Conclusion: The presence of a paraspinal fluid collection or epidural abscess is correlated with positive biopsy yield, and paraspinal fluid collections should be targeted for biopsy. Other imaging findings did not correlate with biopsy yield. Biopsy may not offer additional information for patients with positive blood cultures.
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http://dx.doi.org/10.1007/s00256-021-03735-6DOI Listing
February 2021

Cooled Radiofrequency Genicular Neurotomy.

Authors:
Felix M Gonzalez

Tech Vasc Interv Radiol 2020 Dec 5;23(4):100706. Epub 2020 Oct 5.

Department of Radiology and Imaging Sciences, Division of Musculoskeletal Radiology, Emory University School of Medicine, Atlanta, GA. Electronic address:

Knee osteoarthritis, a chronic degenerative condition, can be a debilitating and limiting process with affected patients presenting with symptoms such as pain, restrictive range of motion, and swelling. This condition commonly afflicts millions of people with a higher incidence among the elderly that results from chronic mechanical repetitive loading. The treatment of pain generating conditions such as arthritis in large joints is complex requiring interventions of varying focuses such as weight loss, anti-inflammatory medications, corticosteroid, hyaluronic and viscosupplementation injections, and prescription opioids. A gap in the treatment options of this ailment currently exists between short term pain solutions and surgical approaches such as total knee arthroplasty that may offer longer pain relief. Cooled radiofrequency ablation is an emerging technique that offers a minimally invasive alternative for treating knee pain with a clinical relevance in patients who are not surgical candidates due to coexistent medical comorbidities or those who are undesiring of surgery. This procedure uses radiofrequency ablation that blocks genicular nerves from transmitting knee pain signals to the brain. Further research will allow the application of this technique to treat other sensory nerves in large joints such as the hip and shoulder.
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http://dx.doi.org/10.1016/j.tvir.2020.100706DOI Listing
December 2020

Do Not Judge an Ossicle by Its Size: Type 1 Ossicles Associated With Posterior Tibial Tendon Dysfunction.

J Comput Assist Tomogr 2020 Nov/Dec;44(6):993-997

From the Emory Spine and Orthopaedic Center.

Introduction: Patients with type II navicular ossicles have traditionally been considered to be symptomatic, whereas patients with type I and III bones are considered asymptomatic without additional relevant imaging findings. The main objective of this study is to investigate the association of type I os naviculare with clinical symptomology and magnetic resonance imaging findings in comparison to types II and III ossicles.

Methods: Three hundred nine subjects with accessory navicular bone types were identified, and their associations with focal navicular pain, pes planus alignment, ossicle or proximal navicular bone marrow edema pattern presence (BMEP), and posterior tibial tendon (PTT) sheath fluid distension were assessed. Fisher's exact test was used for categorical data and unpaired t tests for continuous data. Intraobserver and interobserver agreement was calculated.

Results: Overall, 28% (85/309) of type I, 57% (176/309) of type II, and 16% (48/309) of type III accessory bones had focal navicular pain (type I vs type II, P = 0.17; type III vs type II, P = 0.001). Thirty-two percent of type I, 38% type II, and 8% type III accessory bones had pes planus (type I vs II, P = 0.3; type III vs type II, P = 0.001). Nine percent of type I, 48% of type II, and 6% of type III accessory bones had BMEP (type I vs II, P < 0.0001; type III vs type II, P = 0.001). Thirty-three percent of type I, 42% of type II, and 6% of type III accessory bones had PTT intrasheath fluid (type I vs II, P = 0.16; type III vs type II, P = 0.001).

Conclusions: Symptomatic type I navicular ossicle patients demonstrate an increased tendency to present with early findings of PTT dysfunction and morphologic pes planus to a greater degree than previously recognized.

Level Of Clinical Evidence: 3.
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http://dx.doi.org/10.1097/RCT.0000000000001089DOI Listing
December 2020

Safety and efficacy comparison of three- vs four-needle technique in the management of moderate to severe osteoarthritis of the knee using cooled radiofrequency ablation.

Skeletal Radiol 2021 Apr 24;50(4):739-750. Epub 2020 Sep 24.

Emory University School of Medicine, Atlanta, GA, USA.

Purpose: To analyze the safety and efficacy of image-guided genicular nerve cooled radiofrequency ablation (C-RFA) for the treatment of pain in non-surgical candidates with moderate to severe knee osteoarthritis (OA) and to compare three- vs four-needle technique.

Method: This retrospective study included 50 consecutive patients with pain from moderate to severe knee OA refractory to anti-inflammatory analgesia that failed multiple intra-articular lidocaine-steroid injections and who were non-surgical total knee arthroplasty candidates because of comorbidities. Patients initially underwent anesthetic blocks of the superior medial/lateral femoral and inferior medial tibial genicular nerve branches and in some cases the suprapatellar genicular nerve branch. Radiofrequency ablations of the same nerve branches were performed 1-2 weeks after the nerve blocks. Follow-up outcome was collected at approximately 2 weeks, 1, 3, and 6 months after the C-RFA procedure utilizing VAS and clinically validated questionnaires.

Results: A total of 77 knees were treated. The mean total KOOS score improved significantly from baseline at 24.7 ± 14.1 to 59.4 ± 26.5 at 6 months after treatment (p < 0.0001), with significant improvement in mean pain score from 25.5 ± 15.2 to 64.5 ± 25.2 (p < 0.0001) and mean stiffness score from 35.1 ± 21.9 to 65.8 ± 24.9 (p < 0.0001). At 6 months, 65% of all patients demonstrated decreased opiate medication usage, 79% of patients in the four-needle, and 45% of patients in the three-needle arms (p = 0.03). No complications were reported.

Conclusions: The four-needle treatment approach offers an advantage in the overall efficacy in treating stiffness and pain in patients with moderate-to-severe OA refractory to conservative treatments leading to decreased opiate usage without complications.
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http://dx.doi.org/10.1007/s00256-020-03619-1DOI Listing
April 2021

Osteoarthritis of the hip: are degenerative tears of the acetabular labrum predictable from features on hip radiographs?

Acta Radiol 2021 May 8;62(5):628-638. Epub 2020 Jul 8.

Emory University School of Medicine, Atlanta, GA, USA.

Background: A common feature of hip arthritis is the presence of labra tears. Recent literature suggests against the use of magnetic resonance imaging (MRI) in patients aged >45 years for the assessment of hip pain related to arthritis.

Purpose: To determine if radiographic features of osteoarthritis detectable on routine hip radiographs are accurate and reliable surrogate markers of degenerative acetabular labral tears identified on MR arthrography (MRA) and corroborated during arthroscopy.

Material And Methods: A retrospective study involving 86 symptomatic patients (hip pain) with radiologic work-up included MRA and pelvic or hip radiographs that underwent hip arthroscopy within three months. Imaging characteristics assessed on hip radiographs include measurements of superior acetabular, femoral head osteophyte, cortical thickness of the femoral shaft, and minimum joint space as well as presence of subchondral sclerosis of the femoral head and acetabulum, femoral shaft buttressing, and grade of arthritis. Presence of a labral tear was determined by consensus between three readers as well as by surgical correlation. The Pearson's chi-squared and Fisher's exact tests were used to compare presence of labral tears with each radiographic feature.

Results: Seventy-one patients (82.6%) had labral tears: 49 (69%) women and 22 (31%) men. Receiver operating characteristic analysis showed statistical significance (<0.05) between presence of a labral tear and acetabular and femoral head osteophyte sizes but failed to demonstrate any significance regarding acetabular subchondral sclerosis, cortical thickness, buttressing, or minimum joint space.

Conclusions: Radiographic markers such as the acetabular and femoral head osteophyte sizes demonstrated statistical significance with the presence of labral tears.
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http://dx.doi.org/10.1177/0284185120936269DOI Listing
May 2021

In vivo Sonographic Characterization of The Achilles Tendons in Healthy Young Collegiate Athletes as a Function of Ankle Position.

J Foot Ankle Surg 2020 Sep - Oct;59(5):898-902. Epub 2020 Jul 3.

Associate Professor of Orthopedics, Department of Orthopaedic Surgery, Emory School of Medicine, Atlanta, GA.

This study aims to describe the normative Achilles tendon properties in a collegiate subject cohort. Achilles tendon evaluations in 65 asymptomatic college-level athletes by ultrasound B mode on two tendon positions (neutral state and active maximum dorsiflexion). Correlation was made to BMI, tibial/foot length, maximal calf circumference, type of sports, resting/maximal dorsiflexion-plantar flexion angles among other factors. The mean Achilles tendon length was found to be 14.9 cm, mean transverse dimension of 1.38 cm, thickness of 0.49 cm and cross-sectional area of 0.61 cm in the relaxed state. Males had greater tendon length than the female athletes (15.5 (M) vs 14.3cm (F) in the relaxed position and 16.1 (M) vs 15.2cm (F) in the stretched position), tendon width (1.4 vs 1.3 cm), tendon thickness (0.51 vs 0.46 cm), tendon cross-sectional area (0.65 vs 0.57 cm) and foot length (27.6 cm vs 26.6 cm). The Achilles tendon parameters such as length in the relaxed state had a statistically significant correlation with the height, weight, and foot length, while the tendon length in the dorsiflexed-stretched position had a statistically significant relationship to foot length, tibia length, calf circumference and range of motion (both in maximum dorsiflexion and plantar flexion positions; p < .05 for all comparison). Differences in the correlation between the Achilles tendon parameters and body habitus was recorded as a function of ankle position. Tendon dimensions and cross-sectional areas were larger in male vs female athletes. Calf circumferences and Achilles tendon resting angle were outlined. No significant difference was found in the Achilles tendon dimensions regardless of the leg dominance with similar range of motion regardless of athlete gender.
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http://dx.doi.org/10.1053/j.jfas.2020.01.009DOI Listing
July 2020

Alternate treatment approach to subchondral insufficiency fracture of the knee utilizing genicular nerve cooled radiofrequency ablation and adjunctive bisphosphonate supplementation: A case report.

Radiol Case Rep 2020 Jun 5;15(6):691-696. Epub 2020 Apr 5.

Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA.

Subchondral insufficiency fractures of the knee are commonly misdiagnosed fractures that are both very painful and difficult to treat. A conservative treatment modality to control symptoms during rehabilitation has not previously been described. This case report presents the alternate use of cooled radiofrequency ablation technique of the genicular nerves for pain relief and bisphosphonate infusion to address the underlying poor bone mineralization/density with imaging follow-up before and after instituted treatments. A middle-aged female patient presenting with atraumatic pain in the medial aspect of the left knee diagnosed on an original magnetic resonance imaging as an insufficiency fracture and debilitating pain. Multiple-surgeon opinions of total knee arthroplasty were not a consideration the patient wanted or could consider given her lifestyle. Cooled radiofrequency ablation of the genicular nerve branches was performed with significant-complete pain relief achieved that lasted at least 6 months. Bisphosphonate infusions were instituted to address the underlying osteoporosis detected by a dual energy X-ray absorptiometry (DEXA) scan. Clinical performance after the radiofrequency ablations was followed with clinically validated surveys (The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)/Knee Injury and Osteoarthritis Outcome Score (KOOS)) at 2 weeks, 1, 3, and 6 months. Patient was also asked to follow a restricted-modified weight-bearing plan for 3 months followed by physical therapy. Eight weeks apart of bisphosphonate infusions were delivered after proper administration of vitamin D. There was resolution of the insufficiency fracture at the medial femoral condyle between the magnetic resonance imaging exams within 4.5 months apart treated with restricted weight-bearing regimen. Pain resolution, significant improved function, and range of motion were the end results of our instituted treatment plan. This case reports presents an alternate pathway for the treatment of this condition especially when there is lack of consensus among physicians in how to best address this condition.
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http://dx.doi.org/10.1016/j.radcr.2020.02.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138926PMC
June 2020

Nomenclature of Subchondral Nonneoplastic Bone Lesions.

AJR Am J Roentgenol 2019 11 24;213(5):963-982. Epub 2019 Jul 24.

Department of Radiology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114.

The purpose of this article is to summarize the nomenclature of nonneoplastic conditions affecting subchondral bone through a review of the medical literature and expert opinion of the Society of Skeletal Radiology Subchondral Bone Nomenclature Committee. This consensus statement summarizes current understanding of the pathophysiologic characteristics and imaging findings of subchondral nonneoplastic bone lesions and proposes nomenclature to improve effective communication across clinical specialties and help avoid diagnostic errors that could affect patient care.
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http://dx.doi.org/10.2214/AJR.19.21571DOI Listing
November 2019

Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome.

Skeletal Radiol 2019 Dec 27;48(12):1961-1974. Epub 2019 Jun 27.

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.

Objective: To propose an magnetic resonance imaging (MRI) grading system for subchondral insufficiency fracture of the knee (SIFK) to predict outcome and assess risk factors.

Materials And Methods: A total of 50 SIFK patients were retrospectively reviewed utilizing two MRI examinations approximately a year apart and compared them with 51 control subjects. A grading system was introduced that classifies lesions as low- vs high-grade. Lesion location 3D dimensions, extent of bone marrow edema (BME), location of meniscal tears and associated extrusion, degree of chondrosis and among other parameters were stratified according to lesion grade and compared with follow-up examinations. Statistical analyses were performed (Pearson's correlation, binary logistic regression, and Chi-squared analysis).

Results: The majority of SIFK lesions were low-grade (LG; 78%) and most of them (70%) were observed in the medial femoral condyle. Predictor variables comparing low-grade and high-grade SIFK lesions included meniscal tear (p = 0.01), degree of extrusion (p < 0.003), chondrosis (p = 0.01), medial chondrosis grade (p = 0.001), medial femoral condyle (p = 0.01), surface collapse (p < 0.0001), marrow edema improvement (p < 0.0001), first MRI anteroposterior dimension (p = 0.001), transverse dimension (p < 0.001), and ellipsoid volume (p = 0.02). Predictor variables found to be significantly different between controls and patients were meniscal tear (p = 0.024), location of the medial meniscal tear (p < 0.0001), degree of extrusion (p < 0.0001), chondrosis (p < 0.0001), joint effusion (p < 0.0001), Baker's cyst (p < 0.0001), knee lock (p = 0.03) and buckle (p = 0.01), and history of trauma (p = 0.01).

Conclusion: A SIFK grading system for MRI is introduced. Surrogate markers of high-grade lesions include medial meniscus posterior root tears with associated moderate to severe extrusion, high-grade chondrosis, larger lesion sizes (anteroposterior/transverse), and articular surface collapse. Improvement of BME on follow-up was highly predictive of low-grade disease.
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http://dx.doi.org/10.1007/s00256-019-03245-6DOI Listing
December 2019

Correlation between subcutaneous fat measurements in knee MRI and BMI: relationship to obesity and related co-morbidities.

Acta Radiol Open 2019 Jun 11;8(6):2058460119853541. Epub 2019 Jun 11.

Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA, USA.

Background: Obesity is a major public health disorder associated with multiple co-morbidities. Knee magnetic resonance imaging (MRI) permits visualization of the subcutaneous fat anatomy, which can be correlated to body mass index (BMI) and obesity-related co-morbidities.

Purpose: This study intends to validate a method of correlating measurements of subcutaneous fat around the distal femur on axial MR images to BMI and obesity-related co-morbidities.

Material And Methods: The most proximal axial slice of each knee MRI was divided into four quadrants. Measurements of the thickest portion of the subcutaneous fat in each quadrant were independently obtained, yielding a value which was assigned the name of the SubCut fat index. The relationship between the SubCut fat index of each quadrant and the patient's BMI was then evaluated. Receiver operating characteristic curves utilizing both the subcutaneous fat in the medial and lateral quadrants as well as BMI were performed with respect to obesity-related co-morbidities.

Results: SubCut fat index measurements in all four quadrants and BMI show the strongest correlation (all four, ANOVA  < 0.0001, r = 0.6), with subcutaneous fat measurements of the anterior medial (p < 0.0001) and posterior medial quadrants ( = 0.01). Additionally, BMI and medial quadrants SubCut indices showed strong association with obesity-related co-morbidities including sleep apnea, asthma, diabetes, hypertension, gastroesophageal reflux disease, and osteoporosis.

Conclusion: The SubCut fat index, a marker of distal femur subcutaneous fat on axial MRI, correlates with severity of obesity (BI) and associated obesity-related co-morbidities.
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http://dx.doi.org/10.1177/2058460119853541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560802PMC
June 2019

Volumetric evaluation of lumbar epidural fat distribution in epidural lipomatosis and back pain in patients who are obese: introducing a novel technique (Fat Finder algorithm).

BMJ Open Diabetes Res Care 2019 17;7(1):e000599. Epub 2019 Mar 17.

Department of Radiology and Imaging Sciences, Emory School of Medicine, Atlanta, Georgia, USA.

Objective: Spinal epidural lipomatosis (EL) represents an excessive deposition of unencapsulated adipose tissue in the spinal canal that can result in chronic back pain in patients who are obese with and without diabetes. We aim to calculate the total volumetric epidural fat on lumbar spine MRI in a predominately obese population and correlate total epidural fat to lower back pain (LBP) and body mass index (BMI).

Research Design And Methods: We developed a program (Fat Finder) to quantify volumetric distribution of epidural fat throughout the lumbar spine. Eleven patients with LBP were imaged using two MRI protocols: parallel axial slices and conventional clinical protocol. The distribution of epidural fat per level was analyzed and normalized to the spinal canal size.

Results: Our sample had an average age of 59.9 years and BMI of 31.57 kg/m. EL subgroup consisted of seven patients. The L2-L5 total fat volume was 3477.6 mm (1431.1-5595.9) in the EL group versus 1783.8 mm (815.0-2717.5) in the age-similar non-EL group. A higher percentage of fat volume in the canal was associated with higher LBP scores. The fat percentage was 32.2% among patients with EL versus 15.4% for age-similar non-EL with LBP score of 6.1 and 4.0, respectively.

Conclusions: The Fat Finder is a novel volumetric method to quantify epidural lumbar spinal fat. The epidural fat favors the lower spinal segment with direct proportionality between the fat volume and LBP score, independent of BMI.
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http://dx.doi.org/10.1136/bmjdrc-2018-000599DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501852PMC
April 2020

Tenosynovial fluid as an indication of early posterior tibial tendon dysfunction in patients with normal tendon appearance.

Skeletal Radiol 2019 Sep 19;48(9):1377-1383. Epub 2019 Feb 19.

Emory University Orthopaedic and Spine Center, 59 Executive Park S, Suite 2000, Atlanta, GA, 30329, USA.

Objective: Our primary aim was to quantify the posterior tibial tendon (PTT) sheath fluid volume in individuals with the clinical diagnosis of stage 1 posterior tibial tendon dysfunction (PTTD) and no MRI-detectable intra-substance tendon pathology and compare them with patients with other causes of medial ankle pain, also without MRI-detectable intra-substance PTT pathology and with normal controls. We also wanted to determine if there is a fluid measurement that correlates with the clinical diagnosis of PTTD.

Materials And Methods: A total of 326 individuals with medial ankle pain and no intra-substance PTT pathology were studied. Group 1 included 48 patients with a clinical diagnosis of stage 1 PTT dysfunction, group 2 comprised 278 patients with other causes of medial ankle pain, and a third control group consisted of 56 patients without any medial ankle pain. MRI-based geometric measurements included PTT fluid volume, maximum cross-sectional fluid area, and fluid width. Fluid measurements were compared between groups and measurement reliability was tested.

Results: Group 1 showed greater PTT fluid volume, area, and width compared with groups 2 (other causes of medial ankle pain) and 3 (asymptomatic controls) (all p values < 0.001). A 9-mm threshold maximum fluid width was associated with PTTD (sensitivity 84%, specificity 85%). Measurements were reliable (all p values < 0.03) among three observers blinded to the gold standard.

Conclusion: Patients with stage 1 PTT dysfunction displayed greater volumes of tendon-sheath fluid than those with other causes of medial ankle pain and compared with asymptomatic controls. A threshold maximum fluid width greater than or equal to 9 mm distinguishes those with PTTD. An association between tendon sheath fluid distension and the clinical diagnosis of stage 1 posterior tibial tendon disease in the setting of no MRI-detectable intra-substance tendon pathology may allow for differentiation of medial ankle pain from other sources and may allow for early intervention aimed at preventing progressive PTTD. The level of evidence was prognostic (level III).
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http://dx.doi.org/10.1007/s00256-018-3142-yDOI Listing
September 2019

Knee MRI Primary Care Ordering Practices for Nontraumatic Knee Pain: Compliance With ACR Appropriateness Criteria and Its Effect on Clinical Management.

J Am Coll Radiol 2019 Mar 12;16(3):289-294. Epub 2018 Dec 12.

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

Purpose: To evaluate the appropriateness of MRI ordering practices and their effect on clinical management for nontraumatic knee pain at the primary care clinics of a large public urban hospital.

Materials And Methods: In all, 196 consecutive MRIs for nontraumatic knee pain ordered from primary care clinics in a large public urban hospital over an 18-month period were studied. ACR Appropriateness Criteria (AC) scores for nontraumatic knee pain were retrospectively calculated from medical record reviews. The record was also reviewed to assess whether knee MRI changed clinical management. Knee osteoarthritis grading was performed. Tests were performed for differences in age, body mass index (BMI), gender, and ethnicity among appropriate and inappropriate MRIs.

Results: Of the MRIs, 57% (108 knees) had "usually appropriate" (ie, 7-9) and 43% (8 knees) had "usually not appropriate" (ie, 1-3) AC scores (P > .1). Clinical management was changed in 26% of knees with "usually appropriate" and 20% of knees with "usually inappropriate" scores (P < .05), and 70% of the knees with "usually appropriate" and 61% of the knee with "usually not appropriate" scores had moderate to severe osteoarthritis. Age, BMI, gender, and ethnicity had no significant effect on AC scores.

Conclusion: In patients referred from primary care for MRI for nontraumatic knee pain, adherence to AC was low. Additional focus on reducing "appropriate" studies that do not impact clinical management (eg, cases with radiographically evident moderate to severe osteoarthritis) is also warranted.
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http://dx.doi.org/10.1016/j.jacr.2018.10.006DOI Listing
March 2019

The Multidisciplinary Approach to the Diagnosis and Management of Nonobstetric Traumatic Brachial Plexus Injuries.

AJR Am J Roentgenol 2018 12 24;211(6):1319-1331. Epub 2018 Sep 24.

5 Department of Radiology and Orthopedic Surgery, University of Texas Southwestern, Dallas, TX.

Objective: Nonobstetric traumatic brachial plexus injuries can result in significant morbidity and chronic disability if not managed in a timely manner. Functional arm recovery is possible, but it requires a multidisciplinary approach toward the diagnosis and management of such injuries.

Conclusion: This article provides an overview of the clinical, electrophysiology, and diagnostic imaging knowledge needed for accurate imaging interpretation and to participate in multidisciplinary discussions aimed at expediting optimal patient management.
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http://dx.doi.org/10.2214/AJR.18.19887DOI Listing
December 2018

Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players.

Radiology 2016 Jun 27;279(3):827-37. Epub 2016 Jan 27.

From the Department of Radiology, Thomas Jefferson University Hospital, Jefferson Medical College, 132 S 10th St, Philadelphia, PA 19107 (J.B.R., F.M.G., A.C.Z., W.B.M., M.T.N., L.N.N.); and Division of Sports Medicine, Department of Orthopedic Surgery, Thomas Jefferson University Hospital, Rothman Institute, Jefferson Medical College, Philadelphia, Pa (M.G.C.).

Purpose To evaluate a combined imaging approach with both ultrasonography (US; conventional US and valgus stress US) and magnetic resonance (MR) arthrography in baseball players with medial elbow pain. Materials and Methods Institutional review board approval was obtained and the requirement for informed consent was waived. The study is compliant with HIPAA. Baseball players with medial elbow pain underwent US in addition to MR arthrography. Findings were assessed with each modality alone and both combined in this retrospective investigation. For the evaluation of ulnar collateral ligament (UCL) tears with stress US, the interval gapping of the medial elbow joint was measured between rest and valgus stress both at the injured and at the uninjured (contralateral) elbow. Surgical or arthroscopic correlation was available as the so-called gold standard. McNemar tests compared the accuracies of the imaging modalities. Results In this study, 144 baseball players had 191 findings of medial elbow pain, including 53 UCL tears. With stress US, joint gapping at the injured elbow greater than 1.0 mm compared with the contralateral elbow yielded a sensitivity, specificity, and accuracy of 96%, 81%, and 87%, respectively, for diagnosing UCL tears. With MR arthrography, the sensitivity, specificity, and accuracy for UCL tears were 81%, 91%, and 88%, respectively, and increased to 96% (P = .013, McNemar test), 99% (P = .023), and 98% (P < .001), respectively, when combined with US to a dual modality MR and US approach. For 31 patients with ulnar neuritis, the sensitivity, specificity, and accuracy increased from 74%, 92%, and 88%, respectively, with MR arthrography alone to 90% (P = .07, McNemar test), 100% (P < .001), and 98% (P < .001) combined with US. For the 59 myotendinous and the 48 osteochondral diagnoses, the sensitivity, specificity, and accuracy with MR arthrography alone were 93%, 93%, and 93%, and 94%, 98%, and 97%, respectively, with no additional diagnostic value from US. Conclusion The combined approach with both MR arthrography and US shows higher accuracy than each modality alone for the assessment of medial elbow pain. (©) RSNA, 2016.
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http://dx.doi.org/10.1148/radiol.2015151256DOI Listing
June 2016

Knee MRI patterns of bone marrow reconversion and relationship to anemia.

Acta Radiol 2016 Aug 21;57(8):964-70. Epub 2015 Oct 21.

Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA.

Background: Bone marrow changes are commonly encountered on knee magnetic resonance imaging (MRI). The clinical relevance of these changes, especially as they relate to anemia, has not been studied in a large patient series.

Purpose: To determine if the extent of bone marrow reconversion (BMR) can assist the radiologist in making recommendations for further evaluation for underlying anemia.

Material And Methods: This study included 457 patients who had knee MRI over a 2-year period. Bone marrow patterns in the distal femur, proximal tibia, and fibula were graded as follows: 1, homogeneous fatty marrow; 2, patchy red marrow in the distal femur; 3, patchy red marrow in the distal femur and tibia and/or fibula; and 4, complete BMR in the femoral, tibial, and/or fibular metaphyses.

Results: There was a statistically significant difference (P < 0.001) between the hemoglobin concentration and BMR grades. In women, anemia (Hb ≤12.0 g/dL) was found in 31 of 127 (24%) patients with grade 1, 31 of 83 (37%) with grade 2, 24 of 64 (37%) with grade 3, and 12 of 24 (50%) with grade 4. In men, anemia (Hb ≤13.0 g/dL) was found in 33 of 125 (26%) patients with grade 1, 12 of 19 (63%) with grade 2, five of 14 (36%) with grade 3, but not in the one patient with grade 4.

Conclusion: Women demonstrating marrow changes of a grade 4 BMR pattern should get a laboratory assessment for anemia.
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http://dx.doi.org/10.1177/0284185115610932DOI Listing
August 2016

Magnetic Resonance Imaging of Sports Injuries Involving the Ankle.

Top Magn Reson Imaging 2015 Aug;24(4):205-13

From the Thomas Jefferson University Hospital, Philadelphia, PA.

Understanding of ankle injuries has evolved for the past few decades, influenced by capability to visualize ligaments, tendons, and bone marrow on magnetic resonance imaging (MRI). Natural history of injury progression, complications, and healing has also been characterized using MRI. Stress injury is particularly common at the ankle in athletes and "weekend warriors" alike. This article will discuss manifestations of ankle injury on MRI as well as associated findings that should be addressed.
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http://dx.doi.org/10.1097/RMR.0000000000000060DOI Listing
August 2015

Frequency, imaging findings, risk factors, and long-term sequelae of distal clavicular osteolysis in young patients.

Skeletal Radiol 2015 May 7;44(5):659-66. Epub 2015 Jan 7.

Division of Musculoskeletal Imaging and Interventions, Department of Radiology, Thomas Jefferson University Hospital, Thomas Jefferson University, 132 South 10th Street, Philadelphia, PA, 19107, USA,

Objective: Atraumatic distal clavicular osteolysis (DCO) has been described in adult male weightlifters. Our purpose was to investigate the frequency, magnetic resonance imaging (MRI) characteristics, risk factors, and long-term sequelae of DCO in young patients.

Materials And Methods: Individuals with atraumatic DCO were identified in a retrospective review of 1,432 consecutive MRI shoulder reports in patients between 13 and 19 years of age. MRI findings of DCO, association with athletic activity, short-term clinical outcome after 3-6 months, and long-term clinical and MRI outcome after 2 years were analyzed. A pre-MRI questionnaire assessed the patients' athletic history including overhead activity and weightlifting.

Results: At a mean age of 15.9 years, 6.5 % (93/1432) of patients had atraumatic DCO, and 24 % were females. The combination of an overhead sport (basketball, volleyball, tennis, swimming) and supplemental weight training was a risk factor for DCO (odds ratio = 38, p = 0.01). Ninety-three percent of patients responded to conservative therapy. On follow-up imaging, 71 % of DCO patients had acromioclavicular (AC) joint osteoarthritis (vs. 35 % in controls, p = 0.006); 79 % had flattening of the distal clavicle and interval widening of the AC joint to a mean of 5.0 mm (compared to 2.4 mm in controls, p < 0.001). Severity of DCO edema was associated with pain (p < 0.02) at initial presentation and with AC joint osteoarthritis (p = 0.004) on follow-up.

Conclusion: In athletic teenagers, the combination of weightlifting and overhead activity is a risk factor for atraumatic DCO, and females are affected in 24 %. Long-term sequelae include widening of the AC joint and AC joint osteoarthritis.
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http://dx.doi.org/10.1007/s00256-014-2092-2DOI Listing
May 2015

Nitrite anion provides potent cytoprotective and antiapoptotic effects as adjunctive therapy to reperfusion for acute myocardial infarction.

Circulation 2008 Jun 2;117(23):2986-94. Epub 2008 Jun 2.

Translational Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1061, USA.

Background: Accumulating evidence suggests that the ubiquitous anion nitrite (NO2-) is a physiological signaling molecule, with roles in intravascular endocrine nitric oxide transport, hypoxic vasodilation, signaling, and cytoprotection. Thus, nitrite could enhance the efficacy of reperfusion therapy for acute myocardial infarction. The specific aims of this study were (1) to assess the efficacy of nitrite in reducing necrosis and apoptosis in canine myocardial infarction and (2) to determine the relative role of nitrite versus chemical intermediates, such as S-nitrosothiols.

Methods And Results: We evaluated infarct size, microvascular perfusion, and left ventricular function by histopathology, microspheres, and magnetic resonance imaging in 27 canines subjected to 120 minutes of coronary artery occlusion. This was a blinded, prospective study comparing a saline control group (n=9) with intravenous nitrite during the last 60 minutes of ischemia (n=9) and during the last 5 minutes of ischemia (n=9). In saline-treated control animals, 70+/-10% of the area at risk was infarcted compared with 23+/-5% in animals treated with a 60-minute nitrite infusion. Remarkably, a nitrite infusion in the last 5 minutes of ischemia also limited the extent of infarction (36+/-8% of area at risk). Nitrite improved microvascular perfusion, reduced apoptosis, and improved contractile function. S-Nitrosothiol and iron-nitrosyl-protein adducts did not accumulate in the 5-minute nitrite infusion, suggesting that nitrite is the bioactive intravascular nitric oxide species accounting for cardioprotection.

Conclusions: Nitrite has significant potential as adjunctive therapy to enhance the efficacy of reperfusion therapy for acute myocardial infarction.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.107.748814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2587279PMC
June 2008

Retrospective determination of the area at risk for reperfused acute myocardial infarction with T2-weighted cardiac magnetic resonance imaging: histopathological and displacement encoding with stimulated echoes (DENSE) functional validations.

Circulation 2006 Apr 10;113(15):1865-70. Epub 2006 Apr 10.

National Heart, Lung and Blood Institute, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD 20892-1061, USA.

Background: The aim of this study was to determine whether edema imaging by T2-weighted cardiac magnetic resonance (CMR) imaging could retrospectively delineate the area at risk in reperfused myocardial infarction. We hypothesized that the size of the area at risk during a transient occlusion would be similar to the T2-weighted hyperintense region observed 2 days later, that the T2-weighted hyperintense myocardium would show partial functional recovery after 2 months, and that the T2 abnormality would resolve over 2 months.

Methods And Results: Seventeen dogs underwent a 90-minute coronary artery occlusion, followed by reperfusion. The area at risk, as measured with microspheres (9 animals), was comparable to the size of the hyperintense zone on T2-weighted images 2 days later (43.4+/-3.3% versus 43.0+/-3.4% of the left ventricle; P=NS), and the 2 measures correlated (R=0.84). The infarcted zone was significantly smaller (23.1+/-3.7; both P<0.001). To test whether the hyperintense myocardium would exhibit partial functional recovery over time, 8 animals were imaged on day 2 and 2 months later. Systolic strain was mapped with displacement encoding with stimulated echoes. Edema, as detected by a hyperintense zone on T2-weighted images, resolved, and regional radial systolic strain partially improved from 4.9+/-0.7 to 13.1+/-1.5 (P=0.001) over 2 months.

Conclusions: These findings are consistent with the premise that the T2 abnormality depicts the area at risk, a zone of reversibly and irreversibly injured myocardium associated with reperfused subendocardial infarctions. The persistence of postischemic edema allows T2-weighted CMR to delineate the area at risk 2 days after reperfused myocardial infarction.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.105.576025DOI Listing
April 2006