Transatlantic Course of ESR and RSNA: Sports Imaging

Postoperative imaging after ACL or cartilage repair is indicated in patients with ongoing pain/instability or repetitive injury. Radiography remains the initial imaging modality; however, a further assessment with CT or MRI is recommended. With a clear emphasis on MRI, we will review normal postoperative findings and complications after ACL reconstructions and cartilage repair. The case discussion will cover the most significant pathologies and pitfalls, and normal postoperative findings will be illustrated.

The major pitfall in musculoskeletal ultrasound-guided procedures is the incorrect diagnosis. Many patients are now referred to the interventional radiologist from other institutions or private practice. Among them, the radiologist in charge of the interventional procedure discovers incomplete or entirely wrong diagnoses. It is then mandatory to get all Imaging and clinical information before doing the procedure. The preparation of the procedure includes in these cases a full study of the images performed elsewhere and a full new ultrasound investigation. A typical example for this is the asking to perform PRP in a rotator cuff for a so-called "partial rupture" which is in fact a "full thickness tear" and not a "intratendinous interstitial tear"The second pitfall is a misunderstanding of the ultrasound possibilities of covering the lesion with the probe AND a safe route for the needle. An example of this is to inject a tear in the distal biceps brachii tendon for PRP or needling treatment. The so-called Cobra position could not demonstrate the tear if too proximal, and from the anterior approach, the tendon is covered by the artery and the nerve, making the procedure irrealistic. The second part of the lecture describes the different techniques of injection: direct or indirect, with different positions and angles of the needle, emphasising the search for the best approach, not only the safest but the one showing best the needle and the target. Some examples will be given involving upper and lower limbs tendon, ligament and joint injections.

For joint abnormalities and tendinopathy, there exist many percutaneous treatment options. Anaesthetic agents are often combined with corticosteroids to inject joints and bursae for diagnostic and therapeutic purposes. All anaesthetic agents are cytotoxic to chondrocytes and synovial cells to some degree. Corticosteroids may be used to decrease inflammation within a synovial space. The use of corticosteroids to treat tendinopathy is counterintuitive, as inflammation is not present, injection into tendon causes tenocyte death, the analgesic effect of corticosteroids is short-lived, and the tendon pathology is not treated. Several ultrasound-guided tendon treatments can be used for tendinopathy. One treatment is tendon fenestration or tenotomy, where a needle is passed through the abnormal tendon segment repeatedly to break up the degenerative process, induce bleeding and inflammation, and initiate tendon healing. Anti-inflammatory medication should be avoided so as not to interfere with the healing response. Another procedure is the injection of autologous whole blood while fenestration, which increases growth factors and other substances to promote tissue healing. Since the majority of growth factors are stored within platelets, the injection of platelet-rich plasma during fenestration has also been used. With this technique, the autologous whole blood is centrifuged to concentrate the platelets for injection. All three of these percutaneous tendon treatments have been shown to be effective, although it is controversial which technique is best. There are more controversial percutaneous tendon treatments, such as injection of mesenchymal stem cells, human amniotic membrane, and deer antler velvet.

Interactive voting will be the main goal of this section lecture. Some cases will be presented to the audience, summarising the previous lecture on pitfalls and techniques of interventional procedures in musculoskeletal ultrasound. Ten questions will follow, performing a good summary about what is important to remember in this field.

The purpose of the interactive case discussions is to emphasise the teaching points made in the prior lecture reviewing injectables, percutaneous fenestration, and tenotomy. One topic to be addressed will be the imaging findings and potential treatment algorithm for greater trochanteric pain syndrome. In this clinical scenario, a true distended and inflamed bursa is not common, and the primary pathology relates to gluteal tendinopathy. Before pursuing an interventional procedure, conservative management such as proper eccentric physical therapy should be exhausted. The next consideration could be an injection of corticosteroid in the subgluteus maximus (or trochanteric bursa) for the primary purpose to provide temporary pain relief so that the patient can tolerate eccentric physical therapy. The corticosteroid injection is not used as an anti-inflammatory agent as true inflammation is not present, and the pain relief is typically short-lived. If the patient again fails eccentric physical therapy, then the patient may be offered percutaneous fenestration, autologous whole blood injection, or platelet-rich plasma injection. While all three have been shown to be effective, it is still unclear which treatment is best. The dramatic differences in cost should be a consideration when selecting the tendon treatment.

Overhead throwing athletes acquire adaptations to the extremes of motion in the dominant shoulder. These changes may aid in pitching, throwing or serving velocity, however for some athletes they might eventually result in an inability to throw with the same velocity. These injuries and adaptations involve capsule, labrum, rotator cuff and biceps tendons, muscles, nerves, and bones. This presentation will review the biomechanics of throwing forces as they relate to the shoulder using baseball as an example. The MR imaging characteristics of the resultant changes in the rotator cuff, superior labrum and osseous structures will also be highlighted.

Purpose: To become familiar with the expected and abnormal MR imaging findings after labral repair, capsular shift/capsulorrhaphy, remplissage and Latarjet/Bristow procedures. Methods and Materials: MR imaging will be used to demonstrate the various normal and abnormal imaging appearances after shoulder instability surgery. Results/Conclusion: Labral re-tear will be evident as contrast or joint fluid extension into linear or complex tear cleft, absent/truncated/fragmented labrum, or labral displacement from an anatomic location. Capsular shift results in smaller capacity joint and sometimes irregular capsular nodularity. Complications of capsulorrhaphy include capsular tears and subluxation of the humeral head. Postoperative MR imaging can evaluate healing after combined remplissage and Bankart repair for moderate size, engaging Hill-Sachs lesions. Laserjet and Bristow procedures may be performed in patients with recurrent dislocations and glenoid deficiency. Incorporated bone will yield non-anatomic glenoid configuration, and complications include non-union, fatty degeneration of subscapularis muscle, and osteoarthrosis.

This interactive session will showcases that relate to the shoulder in the throwing adolescent. This age group has additional problems related to the stress of throwing. These abnormalities were not discussed in the lecture on the throwing shoulder of the adult. Many of the cases relate to stress on the physical plates around the shoulder.

To engage in interactive case discussions with the expected and abnormal MR imaging findings after labral repair, capsular shift/capsulorrhaphy, remplissage and Laterjet/Bristow procedures. An interactive case discussion will be used to demonstrate the various normal and abnormal imaging appearances after shoulder instability surgery. Labral re-tear will be evident as contrast or joint fluid extension into linear or complex tear cleft, absent/truncated/fragmented labrum, or labral displacement from the anatomic location. Capsular shift results in smaller capacity joint and sometimes irregular capsular nodularity. Complications of capsulorrhaphy include capsular tears and subluxation of the humeral head. Postoperative MR imaging can evaluate healing after combined remplissage and Bankart repair for moderate size, engaging Hill-Sachs lesions. Laterjet and Bristow procedures may be performed in patients with recurrent dislocations and lenoid deficiency. Incorporated bone will yield non-anatomic glenoid configuration, and complications include non-union, fatty degeneration of subscapularis muscle, and osteoarthrosis.

Wrist injuries account for 5 % of sports injuries. In the young athlete, fractures are the most common injuries. The hand and wrist are the most common sites for fracture in the young athlete. Physeal injuries are typical overuse injuries in gymnasts. Chronic stress reactions with a widening of the growth plate are seen in the distal radial and less common in the ulnar growth plate. Injuries to the TFCC in the athlete occur in acute trauma and with overuse. TFCC injuries are an important cause for ulnar-sided wrist pain. The differential diagnosis includes ulnar styloid impaction syndrome, ulnar impingement syndrome and tenosynovitis of the extensor carpi ulnaris tendon. Injury to the interosseous ligaments may lead to carpal instability. Chronic injury of the intrinsic or extrinsic ligaments of the wrist may cause ganglion cyst formation.

Ankle injuries are common in many sports, and the complicated anatomy of the ankle joint can be challenging the reporting radiologist. The ankle joint itself is a synovial hinge joint, but the important movement for ankle function also occurs at the joints of the hind and midfoot which are also susceptible to injury. In addition to conventional radiographs, CT, MRI and ultrasound all have important roles to play in the diagnosis of foot and ankle injuries in the athlete. The ligamentous and tendon structures about the ankle are generally superficial in nature and readily amenable to assessment with ultrasound where assessment can be enhanced due to the dynamic capabilities of the technique. While MRI also demonstrates these structures, it has advantages for assessing deeper joint structures such as the chondral surfaces and bones. The complex 3d anatomy of the foot and ankle means that conventional radiographs can struggle to demonstrate bone injury which means CT also has an important role to play. This lecture will focus on the use of these imaging modalities for the assessment of acute and chronic ligamentous and tendon injury. Emphasis will be put on the mechanisms of injury and how they determine the resultant patterns of injury and imaging appearances.

This interactive teaching session will show various cases related to upper extremity sports injuries. Case discussion about soft tissues injuries of the wrist such as TFCC lesions and other wrist and hand injuries in athletes will be done interactively. The differential diagnosis and diagnostic challenges, as well as pitfalls, will be discussed.

Cases will be presented with the opportunity for audience response highlighting and consolidating ideas presented in the preceding lecture. Abstract for that Lecture: Ankle injuries are common in many sports, and the complicated anatomy of the ankle joint can be challenging the reporting radiologist. The ankle joint itself is a synovial hinge joint, but the important movement for ankle function also occurs at the joints of the hind and midfoot which are also susceptible to injury. In addition to conventional radiographs, CT, MRI and ultrasound all have important roles to play in the diagnosis of foot and ankle injuries in the athlete. The ligamentous and tendon structures about the ankle are generally superficial in nature and readily amenable to assessment with ultrasound where assessment can be enhanced due to the dynamic capabilities of the technique. While MRI also demonstrates these structures, it has advantages for assessing deeper joint structures such as the chondral surfaces and bones. The complex 3d anatomy of the foot and ankle means that conventional radiographs can struggle to demonstrate bone injury which means CT also has an important role to play. This lecture will focus on the use of these imaging modalities for the assessment of acute and chronic ligamentous and tendon injury. Emphasis will be put on the mechanisms of injury and how they determine the resultant patterns of injury and imaging appearances.

The anatomy of the normal ACL and menisci will be reviewed, followed by a discussion of the appearances of various abnormalities of the ACL and menisci, as well as mechanisms of injury and injury patterns. Associated injuries will be discussed. Recommendations will be made for imaging the postoperative meniscus.

ACL reconstruction aims to stabilise the knee and prevent chondral and meniscal injuries, which are sequelae of anteroposterior translation and are associated with early osteoarthritis. The idea of the double-bundle ACL graft was to restore normal joint kinematics by anatomic reconstruction of the anteromedial and the posterolateral bundle of the original ACL. This was expected to improve clinical outcomes and restore anterior and rotational knee stability. The single-bundle technique, however, causes less osseous defects and is still a popular technique. Complications, such as ACL graft failure, impingement, cyclops lesion, arthrofibrosis, and patellar inferior syndrome, are discussed. The second part of this presentation will illustrate cartilage repair techniques and imaging findings. The radiologist must be familiar with the different cartilage repair procedures and characteristics in cartilage imaging to evaluate long-term progression or failure. Abnormal postoperative findings include hypertrophic filling, incomplete integration of the transplant into the surrounding cartilage, or subchondral defects, osteophytes, cysts, and persistent bone marrow oedema and joint effusion.