Internal derangements of the shoulder: decision tree and cost-effectiveness analysis of conventional arthrography, conventional MRI, and MR arthrography

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

Frequency of technical success of ultrasound-guided arthrogram injections in children

BACKGROUND

MR arthrography is an essential diagnostic tool to assess and guide management of labral, ligamentous, fibrocartilaginous, and capsular abnormalities in children. While fluoroscopy is traditionally used for intra-articular contrast administration, ultrasound offers advantages of portability and lack of ionizing radiation exposure for both the patient and proceduralist.

OBJECTIVE

The purpose of this retrospective study is to quantify technical success and frequency of complications of ultrasound-guided arthrogram injections at our institution.

MATERIALS AND METHODS

This retrospective analysis investigates the results of 217 ultrasound-guided arthrograms of the shoulder, elbow, and hip in patients aged 5-18 years. Successful injection of contrast into the target joint, clinical indication for MR arthrography, and complications were reviewed.

RESULTS

Accurate ultrasound-guided intra-articular administration of contrast into the target joint was successful for 100% of shoulder cases (90/90), 97% of elbow cases (77/79), and 98% of hip cases (47/48). Leak of contrast outside the target joint occurred in 1.4% (3/217) of cases. No major side effects including excessive bleeding, paresthesia, allergic reactions, or infection occurred during or after the procedure. Additionally, no major vessel, nerve, or tendon complications were observed on MR images.

CONCLUSION

Ultrasound guidance is a reliable, effective, and safe approach to arthrography in children.

Magnetic resonance arthrography of the shoulder: a painful procedure?

Objective

To compare the pain expected to that effectively caused by magnetic resonance arthrography of the shoulder and, secondarily, to describe a simplified approach to the technique for articular access.

Materials and Methods

We prospectively evaluated 40 participants who used a visual analog scale and a simplified categorical scale to indicate the level of pain expected and that experienced after the procedure, comparing the two with the Wilcoxon matched-pairs test. We also determined gender-related differences in pain conditions using the Mann-Whitney U test. In addition, we described a modified technique involving radiographic localization and the use of standard puncture needles for articular access.

Results

Analysis of the visual analog scales showed that the pain experienced was less than had been expected, with median scores of 1.75 and 3.75, respectively (p < 0.001). The level of pain expected was higher among women than among men, with median scores of 8.0 and 3.0, respectively (p = 0.014), as was the level of pain experienced, with median scores of 3.0 and 1.5, respectively (p = 0.139). The overall categorical evaluation corroborated that difference (p = 0.03). Articular access with the modified technique was successful in all patients.

Conclusion

Magnetic resonance arthrography of the shoulder is less painful than patients expect. In addition, digital radiographic guidance combined with the use of standard puncture needles appears to improve the efficiency of the method.

The Posterior Unstable Shoulder: Natural History, Clinical Evaluation and Imaging

Background:

There is a low incidence of posterior instability which is present in only 2% to 10% of all unstable shoulders. The posterior instable shoulder includes different manifestations like fixed dislocation, recurrent subluxation or dislocation.

Methods:

Research and online content related to posterior instability is reviewed. Natural history, clinical evaluation and imaging are described.

Results:

An awareness of the disorder, together with a thoughtful evaluation, beginning with the clinical history, usually leads to proper diagnosis. An appropriate physical exam, taking in account hyperlaxity and specific tests for posterior instability should be done.

Conclusion:

Posterior shoulder instability is an uncommon condition and is challenging to diagnose. There is not a single injury that is responsible for all cases of recurrent shoulder dislocation or subluxation, and the presence of soft tissue lesions or bone alterations should be evaluated, with the use of adequate simple radiology and multiplanar imaging.

Intelligent framework for diagnosis of frozen shoulder using cross sectional survey and case studies

OBJECTIVES

Frozen shoulder is a disease in which shoulder becomes stiff. Accurate diagnosis of frozen shoulder is helpful in providing economical and effective treatment for patients. This research provides the classification of unstructured data using data mining techniques. Prediction results are validated by K-fold cross-validation method. It also provides accurate diagnosis of frozen shoulder using Naïve Bayesian and Random Forest models. At the end results are presented by performance measure techniques.

METHODS

In this research, 145 respondents (patients) with a severe finding of frozen shoulder are included. They are selected on premise of (clinical) assessment confirmed after by MRI. This data is taken from the department of Orthopedics (Pakistan Institute of Medical Sciences Islamabad and Railway Hospital Rawalpindi) between September 2014 to November 2015. Frozen shoulder is categorized on the basis of MRI result. The predictor variables are taken from patient survey and patient reports, which consisted of 35+ variables. The outcome variable is coded into numeric system of "intact" and "no-intact". The outcome variable is assigned into numeric code, 1 for "intact" and 0 for "no-intact". "Intact" group is used as an indication that tissue is damaged badly and "no-intact" is classified as normal. Distribution of result is 110 patients for "Intact" group and 35 patients for "No-Intact" group (false positive rate was 24 %). In this research we have utilized two methods i.e. Naive Bayes and Random Forest. A statistics regression model (Logistic regression) to categorize frozen shoulder finding into "intact" and "no-intact" classes. In the end, we validated our results by Bayesian theorem. This gives a rough estimate about the probability of frozen shoulder.

RESULTS

In this research, our anticipated and predictive procedures gave better outcome as compared to statistical techniques. The specificity and sensitivity ratio of predicting a frozen shoulder are better in the Naïve Bayes as compared to Random Forest. In end the likelihood ratio results are used with Bayesian theorem for final evaluation of the results, from this we conclude predictive model is valid model for classification of frozen shoulder.

CONCLUSIONS

We have used three predictive models in our study to classify frozen shoulder. Then we validated our predictive results by Bayesian theorem to give a rough estimate about the probability of occurrence of disease or not. This enhances the clinical decision making regarding frozen shoulder.

Economics of Musculoskeletal Ultrasound

Purpose of review

Healthcare costs have exploded in the past 30 years and they are a major concern for governments worldwide. Care management of musculoskeletal disorders and advanced imaging account for a large part of this socioeconomic burden.

Recent findings

Musculoskeletal ultrasound is now performed primarily by nonradiologists. Both musculoskeletal ultrasound and MRI total utilization rates continue to increase. Despite the existence of evidence-based diagnostic recommendations and the potential cost-savings of using musculoskeletal ultrasound instead of MRI in certain clinical situations, ensuring appropriate use of imaging among health professionals remains difficult for various reasons.

Summary

In the context of healthcare budgets restraints, use of imaging must be shown scientifically, to improve patient outcomes and be cost-effective. Current evidence recommends musculoskeletal ultrasound as the primary imaging modality in the investigation of rotator cuff disease. Policies aiming at ensuring the application of imaging guidelines among physicians are needed.

Predicting rotator cuff tears using data mining and Bayesian likelihood ratios

OBJECTIVES

Rotator cuff tear is a common cause of shoulder diseases. Correct diagnosis of rotator cuff tears can save patients from further invasive, costly and painful tests. This study used predictive data mining and Bayesian theory to improve the accuracy of diagnosing rotator cuff tears by clinical examination alone.

METHODS

In this retrospective study, 169 patients who had a preliminary diagnosis of rotator cuff tear on the basis of clinical evaluation followed by confirmatory MRI between 2007 and 2011 were identified. MRI was used as a reference standard to classify rotator cuff tears. The predictor variable was the clinical assessment results, which consisted of 16 attributes. This study employed 2 data mining methods (ANN and the decision tree) and a statistical method (logistic regression) to classify the rotator cuff diagnosis into "tear" and "no tear" groups. Likelihood ratio and Bayesian theory were applied to estimate the probability of rotator cuff tears based on the results of the prediction models.

RESULTS

Our proposed data mining procedures outperformed the classic statistical method. The correction rate, sensitivity, specificity and area under the ROC curve of predicting a rotator cuff tear were statistical better in the ANN and decision tree models compared to logistic regression. Based on likelihood ratios derived from our prediction models, Fagan's nomogram could be constructed to assess the probability of a patient who has a rotator cuff tear using a pretest probability and a prediction result (tear or no tear).

CONCLUSIONS

Our predictive data mining models, combined with likelihood ratios and Bayesian theory, appear to be good tools to classify rotator cuff tears as well as determine the probability of the presence of the disease to enhance diagnostic decision making for rotator cuff tears.

Inappropriate requests for magnetic resonance scans of the shoulder

PURPOSE

Magnetic resonance imaging (MRI) scans are a useful investigation for some shoulder pathology. They are costly however and a significant burden on radiology departments. In most cases clinical examination, plain radiography or ultrasound scan (USS) are sufficient for a diagnosis. There are no current UK guidelines regarding MRI shoulder scan requests.

METHODS

We reviewed 100 consecutive MRI shoulder scan requests and the associated formal reports; other investigations were also assessed.

RESULTS

Overall, 56% of MRI scans were ordered inappropriately. Shoulder consultant's requests were more appropriate than other groups (70% vs. 38%. p = 0.04). Excluding shoulder consultants 63 % of scans were inappropriately ordered. Shoulder consultants were more likely to order a preceding X-ray (80% vs. 53% respectively, p = 0.03). Of those with a clinical diagnosis of cuff pathology only 29% had an USS.

CONCLUSION

A high percentage of MRI shoulder scans are performed inappropriately. Shoulder consultants are more appropriate in their ordering than other groups. If all groups performed as well 50 % less MRI scans would need to be performed.

The role of MRI in musculoskeletal practice: a clinical perspective

This clinical perspective presents an overview of current and potential uses for magnetic resonance imaging (MRI) in musculoskeletal practice. Clinical practice guidelines and current evidence for improved outcomes will help providers determine the situations when an MRI is indicated. The advanced competency standard of examination used by physical therapists will be helpful to prevent overuse of musculoskeletal imaging, reduce diagnostic errors, and provide the appropriate clinical context to pathology revealed on MRI. Physical therapists are diagnostically accurate and appropriately conservative in their use of MRI consistent with evidence-based principles of diagnosis and screening.

Economic evaluations in shoulder pathologies: a systematic review of the literature

BACKGROUND

Economic evaluations provide decision makers with a tool for reducing health care costs because they assess both the costs and consequences of health care interventions. This study reviewed the quality of published economic evaluations for shoulder pathologies.

MATERIALS AND METHOD

A MEDLINE search was conducted to identify articles published from 1980 to 2010 that contained "cost" or "economic" combined with terms for several shoulder disorders and treatments. We selected studies that fit the definition of 1 of the 4 routinely performed economic evaluations: cost-minimization, cost-effectiveness, cost-utility, and cost-benefit analyses. Study quality was determined by measuring adherence to 6 established health economic principles, as described in the literature.

RESULTS

The search retrieved 942 studies. Of these, 32 were determined to be economic evaluations, and 53% of the economic evaluations were published from 2005 to 2010. Only 8 of the 32 studies (25%) adhered to all 6 health economic principles. Publication in a nonsurgical journal (P < .05) or in more recent years (P < .01) was significantly associated with higher quality.

CONCLUSION

Future health care resource allocation will likely be based on the economic feasibility of treatments. Although the number and quality of economic evaluations of shoulder disorders have risen in recent years, the current state of the literature is poor. Given that availability of such data may factor in private and public reimbursement decisions, there is a clear demand for more rigorous economic evaluations.

Technical update on magnetic resonance imaging of the shoulder

Improvement in both hardware and software has opened up new opportunities in magnetic resonance (MR) imaging of the shoulder. MR imaging at 3-T has become a reality, with the prospect of 7-T imaging on the horizon. The art of MR arthrography continues to improve, aided by the use of novel imaging positions. New techniques for three-dimensional imaging, the reduction of metal artifact, and biochemical imaging of cartilage hold great promise.

A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions

BACKGROUND

The reported accuracy of clinical tests for superior labral anterior posterior lesions is extremely variable. Pooling results from multiple studies of higher quality is necessary to establish the best clinical tests to use.

HYPOTHESIS

Certain clinical tests are superior to others for diagnosing the presence or absence of a superior labral anterior posterior lesion.

STUDY DESIGN

Meta-analysis.

METHODS

A literature search of MEDLINE (1966-2007), CINAHL (1982-2007), and BIOSIS (1995-2007) was performed for (labrum OR labral OR SLAP OR Bankart) AND (shoulder OR shoulder joint OR glenoid) AND (specificity OR sensitivity AND specificity). Identified articles were reviewed for inclusion criteria. Sensitivity and specificity values were recorded from each study and used for meta-analysis.

RESULTS

Six of 198 identified studies satisfied the eligibility criteria. Active compression, anterior slide, crank, and Speed tests were analyzed using receiver operating characteristic curves. The accuracy of the anterior slide test was significantly inferior to that of the active compression, crank, and Speed tests. There was no significant difference in test accuracy found among active compression, crank, and Speed tests. Between studies, methodological scores did not significantly affect sensitivity and specificity values.

CONCLUSION

The anterior slide test is a poor test for detecting the presence of a labral lesion in the shoulder. Active compression, crank, and Speed tests are more optimal choices. Clinicians should choose the active compression test first, crank second, and Speed test third when a labral lesion is suspected.

The effectiveness of diagnostic imaging methods for the assessment of soft tissue and articular disorders of the shoulder and elbow

There are no clear guidelines for diagnostic imaging of articular and soft tissue pathologies of the shoulder and elbow. Several methods are used, including magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and ultrasound (US). Their cost-effectiveness is still unclear. We performed a meta-analysis of the relevant literature and discussed the role of MR imaging of the shoulder and elbow compared with other diagnostic imaging modalities. For the shoulder impingement syndrome and rotator cuff tears, MRI and US have a comparable accuracy for detection of full-thickness rotator cuff tears. MRA and US might be more accurate for the detection of partial-thickness tears than MRI. Given the large difference in cost of MR and US, ultrasound may be the most cost-effective diagnostic method for identification of full-thickness tears in a specialist hospital setting (Evidence level 3). Both MRA and CT arthrography (CTA) are effective methods for the detection of labrum tears. More recently, multidetector CTA has offered the advantages of thinner slices than with MRA in a shorter examination time. Still, MRA has the advantage towards CTA to directly visualize the affected structures with a better evaluation of extent and location and to detect associated capsuloligamentous injuries. For the elbow pathologies, plain MRI or MRA have the advantage towards CTA to detect occult bone injuries. CTA is better for the assessment of the thin cartilage of the elbow. Both US and MRI are reliable methods to detect chronic epicondylitis; US is more available and far more cost-effective (Evidence level 2). MRA can differentiate complete from partial tears of the medial collateral ligament. US or MRI can detect partial and complete biceps tendon tears and/or bursitis. MRI can provide important diagnostic information in lesions of the ulnar, radial, or median nerve.

Recurrent posterior shoulder instability

Recurrent posterior shoulder instability is an uncommon condition. It is often unrecognized, leading to incorrect diagnoses, delays in diagnosis, and even missed diagnoses. Posterior instability encompasses a wide spectrum of pathology, ranging from unidirectional posterior subluxation to multidirectional instability to locked posterior dislocations. Nonsurgical treatment of posterior shoulder instability is successful in most cases; however, surgical intervention is indicated when conservative treatment fails. For optimal results, the surgeon must accurately define the pattern of instability and address all soft-tissue and bony injuries present at the time of surgery. Arthroscopic treatment of posterior shoulder instability has increased application, and a variety of techniques has been described to manage posterior glenohumeral instability related to posterior capsulolabral injury.