Publications by authors named "Kenneth S Lee"

62 Publications

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

Spatial-frequency Analysis of the Anatomical Differences in Hamstring Muscles.

Ultrason Imaging 2021 03;43(2):100-108

University of Wisconsin-Madison, Madison, WI, USA.

Spatial frequency analysis (SFA) is a quantitative ultrasound method that characterizes tissue organization. SFA has been used for research involving tendon injury, but may prove useful in similar research involving skeletal muscle. As a first step, we investigated if SFA could detect known architectural differences within hamstring muscles. Ultrasound B-mode images were collected bilaterally at locations corresponding to proximal, mid-belly, and distal thirds along the hamstrings from 10 healthy participants. Images were analyzed in the spatial frequency domain by applying a two-dimensional Fourier Transform in all 6.5 × 6.5 mm kernels in a region of interest corresponding to the central portion of the muscle. SFA parameters (peak spatial frequency radius [PSFR], maximum frequency amplitude [Mmax], sum of frequencies [Sum], and ratio of Mmax to Sum [Mmax%]) were extracted from each muscle location and analyzed by separate linear mixed effects models. Significant differences were observed proximo-distally in PSFR ( = .039), Mmax ( < .0001), and Sum ( < .0001), consistent with architectural descriptions of the hamstring muscles. These results suggest that SFA can detect regional differences of healthy tissue structure within the hamstrings-an important finding for future research in regional muscle structure and mechanics.
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http://dx.doi.org/10.1177/0161734621990707DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952215PMC
March 2021

ACR Appropriateness Criteria® Acute Trauma to the Ankle.

J Am Coll Radiol 2020 Nov;17(11S):S355-S366

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Acute injuries to the ankle are frequently encountered in the setting of the emergency room, sport, and general practice. This ACR Appropriateness Criteria defines best practices for imaging evaluation for several variants of patients presenting with acute ankle trauma. The variants include scenarios when Ottawa Rules can be evaluated, when there are exclusionary criteria, when Ottawa Rules cannot be evaluated, as well as specific injuries. Clinical scenarios are followed by the imaging choices and their appropriateness with an accompanying narrative explanation to help physicians to order the most appropriate imaging test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.09.014DOI Listing
November 2020

Ultrasound-guided microwave ablation in the treatment of inguinal neuralgia.

Skeletal Radiol 2021 Mar 30;50(3):475-483. Epub 2020 Sep 30.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 E. Highland Avenue, Madison, WI, 53792, USA.

Chronic groin pain can be due to a variety of causes and is the most common complication of inguinal hernia repair surgery. The etiology of pain after inguinal hernia repair surgery is often multifactorial though injury to or scarring around the nerves in the operative region, namely the ilioinguinal nerve, genital branch of the genitofemoral nerve, and the iliohypogastric nerve, is thought to be a key factor in causing chronic post-operative hernia pain or inguinal neuralgia. Inguinal neuralgia is difficult to treat and requires a multidisciplinary approach. Radiologists play a key role in the management of these patients by providing accurate image-guided injections to alleviate patient symptoms and identify the pain generator. Recently, ultrasound-guided microwave ablation has emerged as a safe technique, capable of providing durable pain relief in the majority of patients with this difficult to treat condition. The objectives of this paper are to review the complex nerve anatomy of the groin, discuss diagnostic ultrasound-guided nerve injection and patient selection for nerve ablation, and illustrate the microwave ablation technique used at our institution.
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http://dx.doi.org/10.1007/s00256-020-03618-2DOI Listing
March 2021

Contrast-enhanced ultrasound-guided musculoskeletal biopsies: our experience and technique.

Skeletal Radiol 2021 Apr 15;50(4):673-681. Epub 2020 Sep 15.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 E. Highland Avenue, Madison, WI, 53792, USA.

Objective: To present our experience with contrast-enhanced ultrasound (CEUS)-guided musculoskeletal soft tissue biopsies in a busy interventional clinic.

Materials And Methods: After IRB approval was obtained and informed consent was waived, we retrospectively reviewed all CEUS-guided musculoskeletal biopsies performed from December 1, 2018 to March 2, 2020. Relevant pre-procedure imaging was reviewed. Number of samples, suspected necrosis on pre-procedure imaging, specimen adequacy for pathologic analysis, correlation with pathologic diagnosis of surgical resection specimens, and procedural complications were recorded.

Results: Thirty-six CEUS-guided musculoskeletal biopsies were performed in 32 patients (mean age 57, range 26-88; 22 males, 10 females). All procedures were performed using 16-gauge biopsy needles, and all procedures provided adequate samples for pathologic analysis as per the final pathology report. Between two and seven core specimens were obtained (mean 3.7). In 30/36 cases (83%), a contrast-enhanced MRI was obtained prior to biopsy, and 10/30 (33%) of these cases showed imaging features suspicious for necrosis. In 15/36 cases, surgical resection was performed, and the core biopsy and surgical resection specimens were concordant in 14/15 cases (93%). One patient noted transient leg discomfort at the time of microbubble bursting. Otherwise, no adverse reactions or procedural complications were observed.

Conclusion: CEUS is an accurate way to safely target representative areas of soft tissue lesions for biopsy and can be implemented in a busy interventional clinic. Our early experience has shown this to be a promising technique, especially in targeting representative areas of heterogeneous lesions and lesions with areas of suspected necrosis on prior imaging.
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http://dx.doi.org/10.1007/s00256-020-03604-8DOI Listing
April 2021

Intra-session and inter-rater reliability of spatial frequency analysis methods in skeletal muscle.

PLoS One 2020 10;15(7):e0235924. Epub 2020 Jul 10.

Department of Orthopedics & Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, United States of America.

Spatial frequency analysis (SFA) is a quantitative ultrasound (US) method originally developed to assess intratendinous tissue structure. This method may also be advantageous in assessing other musculoskeletal tissues. Although SFA has been shown to be a reliable assessment strategy in tendon tissue, its reliability in muscle has not been investigated. The purpose of this study was to examine the reliability of spatial frequency parameter measurement for a large muscle group within a healthy population. Ten participants with no history of lower extremity surgery or hamstring strain injury volunteered. Longitudinal B-mode images were collected in three different locations across the hamstring muscles. Following a short rest, the entire imaging procedure was repeated. B-mode images were processed by manually drawing a region of interest (ROI) about the entire muscle thickness. Four spatial frequency parameters of interest were extracted from the image ROIs. Intra- and inter-rater reliabilities of extracted SFA parameters were performed. Test-retest reliability of the image acquisition procedure was assessed between repeat trials. Intraclass correlation coefficients showed high intra- and inter-rater reliability (ICC(3,1) > 0.9 for all parameters) and good to moderate test-retest reliability (ICC(3,1) > 0.50) between trials. No differences in parameter values were observed between trials across all muscles and locations (p > 0.05). The high reliability metrics suggest that SFA will be useful for future studies assessing muscle tissue structure, and may have value in assessing muscular adaptations following injury and during recovery.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235924PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351217PMC
September 2020

Ultrashort echo time (UTE) imaging reveals a shift in bound water that is sensitive to sub-clinical tendinopathy in older adults.

Skeletal Radiol 2021 Jan 8;50(1):107-113. Epub 2020 Jul 8.

Department of Mechanical Engineering, University of Wisconsin-Madison, 1513 University Ave, Madison, WI, 53706, USA.

Objective: Use ultrashort echo time (UTE) magnetic resonance imaging to quantify bound water components of asymptomatic older Achilles tendons and investigate the relationship between UTE findings and imaging assessment of sub-clinical tendinopathy.

Materials And Methods: Thirteen young (age 25 ± 4.8) and thirteen older (age 67 ± 4.7) adults were tested. A UTE sequence was used to quantify the transverse relaxation times of bound ([Formula: see text]) and free ([Formula: see text]) water and the bound water fraction (F) in the Achilles tendon. Anatomical images were collected and graded by a musculoskeletal radiologist to identify signs of sub-clinical tendinopathy. Two-sample t tests were used to compare [Formula: see text], [Formula: see text], and F between age groups and between adults with and without sub-clinical tendinopathy.

Results: Older tendons exhibited a 60% longer [Formula: see text] (p = 0.004), similar [Formula: see text] (p = 0.86), and 5% smaller F (p = 0.048) than young tendons. Seven older adult tendons exhibited tendon thickening and increased signal intensity indicative of sub-clinical tendinopathy. This subset of tendons exhibited a 7% smaller bound water fraction (p = 0.02) and significantly longer [Formula: see text] (p < 0.001) than the normal tendons from young and older adults.

Conclusion: Older adult tendons exhibited unique UTE signatures that are consistent with disruption of the collagen fiber network and changes in macromolecular content. UTE imaging metrics were sensitive to early indicators of tissue degeneration identified on anatomical images and hence could provide a quantitative biomarker by which to track changes in tissue health resulting from injury, disease, and treatment.
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http://dx.doi.org/10.1007/s00256-020-03538-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677198PMC
January 2021

ACR Appropriateness Criteria® Acute Trauma to the Foot.

J Am Coll Radiol 2020 May;17(5S):S2-S11

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Acute injuries to the foot are frequently encountered in the emergency room and in general practice settings. This publication defines best practices for imaging evaluations for several variants of patients presenting with acute foot trauma. The variants include scenarios when the Ottawa rules can be evaluated, when there are exclusionary criteria, and when suspected pathology is in anatomic areas not addressed by the Ottawa rules. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.019DOI Listing
May 2020

ACR Appropriateness Criteria® Acute Trauma to the Knee.

J Am Coll Radiol 2020 May;17(5S):S12-S25

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Acute trauma to the knee is a common presentation seen in the emergency department. After a routine clinical examination, imaging is frequently performed to facilitate the diagnosis and almost always starts with radiographs. If clinically indicated, advanced cross-sectional imaging may then be performed for further evaluation. CT is often performed for preoperative planning of the complex tibial plateau and distal femur fractures. Currently, MRI is the study of choice for evaluation of bone marrow, internal derangements, and other soft-tissue injuries about the knee joint. In patients with knee dislocations, MR angiography may be performed simultaneously with MRI for evaluation of internal derangements and vascular injuries with less morbidity compared to conventional angiography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.041DOI Listing
May 2020

Shoulder MR Imaging Versus Ultrasound: How to Choose.

Magn Reson Imaging Clin N Am 2020 May 26;28(2):317-330. Epub 2020 Feb 26.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, E3/342, Madison, WI 53792, USA.

Imaging evaluation of the shoulder is performed using multiple modalities, including ultrasound (US) and MR imaging. Clinicians often wonder which modality to use to work up their patients with shoulder pain. Although MR imaging has remained the workhorse of shoulder imaging, US has increased in popularity among academic and private institutions. Both modalities offer similar diagnostic information in regards to rotator cuff pathology and other soft tissues, although they differ in their technique, indications, and interpretation. A thorough understanding of these differences is imperative to appropriately use these modalities in clinical practice, including the unique interventional opportunities available with US.
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http://dx.doi.org/10.1016/j.mric.2019.12.012DOI Listing
May 2020

Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging.

Appl Clin Inform 2020 01 19;11(1):142-152. Epub 2020 Feb 19.

Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States.

Background: Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program.

Objectives: To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US.

Methods: We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data.

Results: During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS "co-designed" in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders ( < 0.001), with concomitant decrease in MRI. Ordering appropriateness more than doubled from 31% (105/335) to 67% (157/234) following CDS ( < 0.001). Interviews confirmed that generalist providers want help in appropriately ordering advanced imaging.

Conclusion: Partnering with medical providers to co-design CDS reduced barriers and prompted appropriate transition to US from MRI for shoulder pain diagnosis, promoting evidence-based practice. This approach can inform the development and implementation of other forms of CDS.
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http://dx.doi.org/10.1055/s-0040-1701256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7030958PMC
January 2020

US-guided Musculoskeletal Interventions in the Hip with MRI and US Correlation.

Radiographics 2020 Jan-Feb;40(1):181-199. Epub 2019 Nov 22.

From the Department of Radiology, University of British Columbia, Royal Columbian Hospital, 300 Columbia St E, New Westminster, BC, Canada V3L 3W7 (J.I.B.); Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, Utah (B.Y.C.); and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (P.M., K.S.L.).

Hip pain is a commonly reported primary symptom with many potential causes. The causal entity can remain elusive, even after clinical history review, physical examination, and diagnostic imaging. Although there are many options for definitive treatment, many of these procedures are invasive, are associated with risk of morbidity, and can be unsuccessful, with lengthy revision surgery required. Percutaneous musculoskeletal intervention is an attractive alternative to more invasive procedures and an indispensable tool for evaluating and managing hip pain. US is an ideal modality for imaging guidance owing to its low cost, portability, lack of ionizing radiation, and capability for real-time visualization of soft-tissue and bone structures during intervention. The authors review both common and advanced US-guided procedures involving the pelvis and hip, including anesthetic and corticosteroid injections, percutaneous viscosupplementation, platelet-rich plasma injection to promote tendon healing, and microwave ablation for neurolysis. In addition, specific anatomic structures implicated in hip pain are discussed and include the hip joint, iliopsoas bursa, ilioinguinal nerve, lateral femoral cutaneous nerve, greater trochanteric bursa, iliotibial band, ischiogluteal bursa, hamstring tendon origin, piriformis muscle, and quadratus femoris muscle. The relevant US-depicted anatomy and principles underlying technically successful interventions also are discussed. Familiarity with these techniques can aid radiologists in assuming an important role in the care of patients with hip pain. RSNA, 2019.
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http://dx.doi.org/10.1148/rg.2020190094DOI Listing
February 2021

Denervation Edema of Hamstring Muscles Following Acute Strain Injury.

J Orthop Sports Phys Ther 2019 10;49(10):761

A 20-year-old male American football player sustained a first-time, left hamstring strain injury (HSI) during competition. Magnetic resonance imaging indicated involvement of the biceps femoris long head (BFLH) and semitendinosus (ST). Following 3 weeks of rehabilitation, the athlete returned to competition without further incident. Fourteen weeks after injury, magnetic resonance imaging was repeated as part of an ongoing study monitoring HSI recovery. Despite full athletic function, imaging revealed atrophy and increased signal intensity of the BFLH and a portion of the ST. Further testing and examination indicated subacute denervation edema. .
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http://dx.doi.org/10.2519/jospt.2019.8598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045722PMC
October 2019

ACR Appropriateness Criteria Acute Hip Pain-Suspected Fracture.

J Am Coll Radiol 2019 May;16(5S):S18-S25

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Acute hip pain following a low-force trauma such as a ground-level fall is a common clinical problem. In the elderly osteoporotic population, this is frequently the result of fractures of the proximal femur or pelvis. As physical examination is often inconclusive, imaging is critical for diagnosis. Radiographs are the preferred first-line imaging modality, although their sensitivity is limited for nondisplaced fractures and further imaging may be necessary as discussed in this article and summarized in the recommendations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.02.028DOI Listing
May 2019

Ultrasound-Guided Microwave Ablation for the Management of Inguinal Neuralgia: A Preliminary Study with 1-Year Follow-up.

J Vasc Interv Radiol 2019 02;30(2):242-248

Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792.

Purpose: To evaluate the feasibility and efficacy of ultrasound-guided microwave ablation for the treatment of inguinal neuralgia.

Materials And Methods: A retrospective review of 12 consecutive ultrasound-guided microwave ablation procedures was performed of 10 consecutive patients (8 men, 2 women; mean age, 41 years [range, 15-64 years]), between August 2012 and August 2016. Inclusion criteria for inguinal neuralgia included clinical diagnosis of chronic inguinal pain (average, 17.3 months [range, 6-46 months]) refractory to conservative treatment and a positive nerve block. Pain response-reduction of pain level and duration and percent pain reduction using a 10-point visual analog scale (VAS) at baseline and up to 12 months after the procedure-was measured. Nine patients had pain after the inguinal hernia repair, and 1 patient had pain from the femoral artery bypass procedure. The microwave ablation procedure targeted the ilioinguinal nerve in 7 cases, the genitofemoral nerve in 4 cases, and the iliohypogastric nerve in 1 case.

Results: Average baseline VAS pain score was 6.1 (standard deviation, 2.5). Improved pain levels immediately after the procedure and at 1, 6, and 12 months were statistically significant (P = .0037, .0037, .0038, .0058, respectively). Also, 91.7% (11/12) of the procedures resulted in immediate pain relief and at 1 month and 6 months. At 12 months, 83.3% (10/12) of patients had an average of 69% ± 31% pain reduction. Percent maximal pain reduction was 93% ± 14% (60%-100%), and the average duration of clinically significant pain reduction was 10.5 months (range, 0-12 months.). No complications or adverse outcomes occurred.

Conclusions: Ultrasound-guided microwave ablation is an effective technique for the treatment of inguinal neuralgia after herniorrhaphy.
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http://dx.doi.org/10.1016/j.jvir.2018.10.031DOI Listing
February 2019

ACR Appropriateness Criteria Chronic Knee Pain.

J Am Coll Radiol 2018 Nov;15(11S):S302-S312

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Chronic knee pain is a condition that is frequently encountered. Imaging often plays an important role in narrowing down the potential causes and determining the most effective next steps. The ACR Appropriateness Criteria for Chronic Knee Pain provides clinicians with the best practices for ordering imaging examinations. The following narrative and accompanying tables should serve as useful guides to any clinician. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2018.09.016DOI Listing
November 2018

Ultrasound Intervention of the Lower Extremity/Pelvis.

Radiol Clin North Am 2018 Nov;56(6):1035-1046

Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/366, 600 Highland Avenue, Madison, WI 53792, USA.

Musculoskeletal (MSK) conditions are growing in prevalence. Ultrasound (US) is increasingly used for managing MSK conditions due to its low cost and ability to provide real-time image guidance during therapeutic interventions. As MSK US becomes more widespread, familiarity and comfort with US-guided interventions will become increasingly important. This article focuses on general concepts regarding therapeutic US-guided injections of corticosteroids and platelet-rich plasma and highlights several of the US-guided procedures commonly performed, involving the pelvis and lower extremity.
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http://dx.doi.org/10.1016/j.rcl.2018.06.011DOI Listing
November 2018

Diagnostic accuracy of an abbreviated MRI protocol for detecting radiographically occult hip and pelvis fractures in the elderly.

Skeletal Radiol 2019 Jan 18;48(1):103-108. Epub 2018 Jun 18.

Department of Radiology, University of Wisconsin Madison School of Medicine and Public Health, Clinical Sciences Center, 600 Highland Avenue, Madison, WI, 53792-3252, USA.

Objective: To determine the diagnostic accuracy of an abbreviated, two-sequence MRI protocol using limited pulse sequences for the detection of radiographically occult hip and pelvis fractures in the elderly compared to the complete MRI examination.

Materials And Methods: One hundred and eleven consecutive emergency department patients age 65 or older who had undergone MRI to evaluate for clinically suspected hip fracture after negative radiographs were included in the study. The large field-of-view coronal T1 and STIR sequences were isolated from the complete six-sequence MRI protocol and reviewed independently in a blinded fashion by two musculoskeletal fellowship-trained radiologists who recorded presence or absence of fractures of the proximal femora or pelvis, fracture type, and presence or absence of soft tissue injury. Test accuracy was calculated with 95% confidence intervals and accuracy of fracture classification for the abbreviated protocol was compared to that made on the basis of the full exam.

Results: For proximal femoral fractures, the abbreviated protocol had a pooled sensitivity and specificity for the two readers of 100 and 97%, respectively. For pelvic fractures, sensitivity was 92% and specificity was 98%. The kappa coefficient for fracture classification was 0.90 for reader 1 and 0.88 for reader 2, indicating excellent agreement for both readers in fracture classification compared to the classification made based on the complete MRI protocol.

Conclusions: An abbreviated MRI protocol that includes only coronal T1 and STIR sequences maintains high sensitivity and specificity for hip and pelvis fracture detection and fracture classification.
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http://dx.doi.org/10.1007/s00256-018-3004-7DOI Listing
January 2019

ACR Appropriateness Criteria Chronic Ankle Pain.

J Am Coll Radiol 2018 May;15(5S):S26-S38

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2018.03.016DOI Listing
May 2018

ACR Appropriateness Criteria Shoulder Pain-Traumatic.

J Am Coll Radiol 2018 May;15(5S):S171-S188

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Traumatic shoulder pain is pain directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). Imaging assessment of traumatic shoulder pain begins with conventional radiography and, depending on physical examination findings, will require MRI or MR arthrography for assessment of soft-tissue injuries and CT for delineation of fracture planes. Ultrasound excels in assessment of rotator cuff injuries but has limited usefulness for assessment of the deep soft-tissues. CT angiography and conventional arteriography are helpful for assessment of vascular injury, and bone scintigraphy can be used in assessment of complex regional pain syndrome after traumatic shoulder injury. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2018.03.013DOI Listing
May 2018

Evidence of Generalized Muscle Stiffness in the Presence of Latent Trigger Points Within Infraspinatus.

Arch Phys Med Rehabil 2018 11 28;99(11):2257-2262. Epub 2018 Apr 28.

School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI; Department of Radiology, University of Wisconsin Hospitals and Clinics, Madison, WI.

Objective: To evaluate stiffness of infraspinatus muscle tissue, both with and without latent trigger points, using ultrasound shear wave elastography (SWE). The primary hypothesis is that muscle with a latent trigger point will demonstrate a discrete region of increased shear wave speed. The secondary hypothesis is that shear wave speed (SWS) in the region with the trigger point will be higher in patients compared with controls, and will be similar between the two groups in the uninvolved regions.

Design: Case-control.

Setting: Hospital-based outpatient physical therapy center.

Participants: Convenience sample (N=18) of patients (6 female, 3 male, mean age=44) (range=31-61y) diagnosed with latent trigger points in infraspinatus and matched controls without trigger points.

Main Outcome Measures: Shear wave speed (m/s).

Results: SWS of the latent trigger point (mean=4.09±SD1.4 m/s) did not differ from the adjacent muscle tissue (3.92±1.6 m/s, P>.05), but was elevated compared to corresponding tissue in controls (2.8±0.75 m/s, P=.02). SWS was generally greater in patients' uninvolved tissue (3.83±1.6 m/s) when compared to corresponding tissue in controls (2.62±0.2 m/s, P=.05).

Conclusion: Although discrete regions of increased SWS corresponding to the trigger point were not observed in patients, evidence of generally increased muscle stiffness in infraspinatus was exhibited compared to healthy controls. Further study of additional muscles with SWE is warranted.
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http://dx.doi.org/10.1016/j.apmr.2018.03.024DOI Listing
November 2018

Axillary Sonography of the Shoulder: An Adjunctive Approach.

J Ultrasound Med 2018 Nov 25;37(11):2707-2715. Epub 2018 Mar 25.

Department of Orthopedic Surgery and Traumatology, Rouen University Hospital, Rouen, France.

Sonography of the shoulder is widely used to assess various disorders, including tendinous diseases of the rotator cuff and the long head of the biceps brachii muscle. The shoulder is commonly explored through anterior, superior, and posterior approaches, but the inferior axillary approach is rarely considered in the literature. However, this technique allows the direct visualization of relevant anatomic structures. The aim of this pictorial essay is, first, to technically describe this approach and the normal musculoskeletal sonographic anatomy of the region and, second, to present the sonographic findings of shoulder disorders that may be helpfully explored this technique.
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http://dx.doi.org/10.1002/jum.14601DOI Listing
November 2018

US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection.

Radiographics 2017 Jul-Aug;37(4):1181-1201

From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.).

Juvenile idiopathic arthritis (JIA) and osteoarticular infection can cause nonspecific articular and periarticular complaints in children. Although contrast material-enhanced magnetic resonance imaging is the reference standard imaging modality, musculoskeletal ultrasonography (US) is emerging as an important adjunct imaging modality that can provide valuable information relatively quickly without use of radiation or the need for sedation. However, diagnostic accuracy requires a systemic approach, familiarity with various US techniques, and an understanding of maturation-related changes. Specifically, the use of dynamic, Doppler, and/or multifocal US assessments can help confirm sites of disease, monitor therapy response, and guide interventions. In patients with JIA, ongoing synovial inflammation can lead to articular and periarticular changes, including synovitis, tenosynovitis, cartilage damage, bone changes, and enthesopathy. Although these findings can manifest in adult patients with rheumatoid arthritis, important differences and pitfalls exist because of the unique changes associated with an immature and maturing skeleton. In patients who are clinically suspected of having osteoarticular infection, the inability of US to evaluate the bone marrow decreases its sensitivity. Therefore, the US findings should be interpreted with caution because juxtacortical inflammation is suggestive, but neither sensitive nor specific, for underlying osteomyelitis. Similarly, the absence of a joint effusion makes septic arthritis extremely unlikely but not impossible. US findings of JIA and osteoarticular infection often overlap. Although certain clinical scenarios, laboratory findings, and imaging appearances can favor one diagnosis over the other, fluid analysis may still be required for definitive diagnosis and optimal treatment. US is the preferred modality for fluid aspiration and administering intra-articular corticosteroid therapy. RSNA, 2017.
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http://dx.doi.org/10.1148/rg.2017160137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548454PMC
November 2017

Preoperative Ultrasound-Guided Wire Localization of the Lateral Femoral Cutaneous Nerve.

Oper Neurosurg (Hagerstown) 2017 06;13(3):402-408

Department of Radiology, University of Wisconsin, Madison, Wisc-onsin.

Background: Difficulty and sometimes inability to find the lateral femoral cutaneous nerve (LFCN) intraoperatively is well known. Variabilities in the course of the nerve are well documented in the literature. In a previous paper, we defined a tight fascial canal that completely surrounds the LFCN in the proximal thigh. These 2 factors sometimes render finding the nerve intraoperatively, to treat meralgia paresthetica, very challenging.

Objective: To explore the use of preoperative ultrasound to minimize operative time and eliminate situations in which the nerve is not found.

Methods: Since 2011, we have used preoperative ultrasound-guided wire localization (USWL) in 19 cases to facilitate finding the nerve intraoperatively. Data were collected prospectively with recording of the timing from skin incision to identifying the LFCN; this will be referred to as the skin-to-nerve time.

Results: In 2 cases, the localization was incorrect. In the 17 cases in which the LFCN was correctly localized, the skin-to-nerve time ranged from 3 min to 19 min. The mean was 8.5 min, and the median was 8 min.

Conclusion: Preoperative USWL is a useful technique that minimizes the time needed to find the LFCN. For the less experienced surgeon, it is extremely valuable. For the experienced surgeon, it can identify anatomical abnormalities such as duplicate nerves, which may not be readily recognizable without ultrasound. Collaboration between the surgeon and the radiologist is very important, especially in the early cases.
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http://dx.doi.org/10.1093/ons/opw009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6312085PMC
June 2017

ACR Appropriateness Criteria Chronic Back Pain Suspected Sacroiliitis-Spondyloarthropathy.

J Am Coll Radiol 2017 May;14(5S):S62-S70

Specialty Chair, Brigham & Women's Hospital, Boston, Massachusetts.

Inflammatory sacroiliitis or the seronegative axial spondyloarthropathies often presents as back pain or sacroiliac joint pain of more than 3-month duration with inflammatory symptoms and typically in patients younger than 45 years of age. Imaging plays an important role in diagnosis and disease monitoring. This article addresses the appropriate sequence of initial imaging for evaluation of a suspected spondyloarthropathy, the imaging follow-up of treatment response and the special considerations for imaging of trauma in patients with ankylosis of the spine. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2017.01.048DOI Listing
May 2017

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

J Am Coll Radiol 2017 May;14(5S):S326-S337

Specialty Chair, Brigham & Women's Hospital, Boston, Massachusetts.

Infection of the musculoskeletal system is a common clinical problem. Differentiating soft tissue from osseous infection often determines the appropriate clinical therapeutic course. Radiographs are the recommend initial imaging examination, and although often not diagnostic in acute osteomyelitis, can provide anatomic evaluation and alternative diagnoses influencing subsequent imaging selection and interpretation. MRI with contrast is the examination of choice for the evaluation of suspected osteomyelitis, and MRI, CT, and ultrasound can all be useful in the diagnosis of soft tissue infection. CT or a labeled leukocyte scan and sulfur colloid marrow scan combination are alternative options if MRI is contraindicated or extensive artifact from metal is present. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2017.02.008DOI Listing
May 2017

Science to Practice: Quantitative US Elastography Can Be Used to Quantify Mechanical and Histologic Tendon Healing in a Rabbit Model of Achilles Tendon Transection.

Radiology 2017 05;283(2):311-313

Department of Radiology University of Wisconsin School of Medicine & Public Health 600 Highland Ave Madison, WI 53792.

Compression-based ultrasonographic (US) elastography is associated with time-dependent mechanical and histologic changes of the healing tendon in a transected rabbit model of the Achilles tendon. This finding will lead to continued development of quantitative US, which can be used to objectively assess a diseased or healing tendon. With advances in the method used, clinical translation of tendon elastography may enable clinicians to diagnose tendon damage and track healing, which should improve both treatment and outcome.
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http://dx.doi.org/10.1148/radiol.2017170126DOI Listing
May 2017

Ultrasound-Guided Platelet-Rich Plasma Treatment: Application and Technique.

Authors:
Kenneth S Lee

Semin Musculoskelet Radiol 2016 Nov 21;20(5):422-431. Epub 2016 Dec 21.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Platelet-rich plasma injection is a minimally invasive treatment method for common overuse tendon injuries. This article discusses the biology of platelet-rich plasma (PRP), the healing cascade that PRP promotes, and how PRP composition may differ depending on centrifuge method. It also highlights the common uses of PRP tendon injection and offers an update on the most current clinical evidence-based literature.
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http://dx.doi.org/10.1055/s-0036-1594287DOI Listing
November 2016

Non-Spine MSK Interventions.

Authors:
Kenneth S Lee

Semin Musculoskelet Radiol 2016 Nov 21;20(5):399-400. Epub 2016 Dec 21.

Department of Musculoskeletal Imaging and Intervention, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

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http://dx.doi.org/10.1055/s-0036-1594279DOI Listing
November 2016