Hot Topics in Orthopedic Imaging

Without question, the stature of the radiologist in both diagnostic and treatment algorithms throughout healthcare has grown significantly in the past decade. As a first year radiology resident, I recall being told by a junior body imaging staff at the Boston Veterans Affairs Hospital that the most rewarding part of her job centered on those times when she was asked to serve as ‘the consultant's consultant’ on a difficult case. Indeed, I find this to be true today in my own career, where my consultant interactions are primarily with orthopedic surgeons and nonoperative sports medicine specialists. In the daily operation of an effective and successful musculoskeletal radiology section or imaging center, our ability to communicate with referring subspecialists and provide them with information accrued through imaging that will be truly useful in creating a treatment plan, is essential. It's great that most radiologists interpreting shoulder MRIs today can accurately diagnose a SLAP lesion even on noncontrast studies, but reviewing an MRI report that leads with the SLAP tear in a 70-year-old patient who also has calcific tendonitis and adhesive capsulitis, drives me crazy. Our duty as consultants is to provide practical information to the managing clinician, not effectively irrelevant minutia. This emphasis on effective communication was firmly imparted to me during the early days of my fellowship by mentors like Mark Schweitzer and David Karasick. I vividly remember a prominent, non-Jefferson-affiliated, orthopedic surgeon telling me after an interdepartmental conference, “Adam, the reason we like to send our patients to you guys is that Mark practices and teaches the 3 A's: Availability, Affability, and Accuracy-in that order!” This idea, one of service and timely, productive communication holding greater importance than perfect and absolutely complete reporting of minutia and fine detail, is certainly distasteful to some radiologists. I accept that divergence in ideology within our specialty. But I propose that the service-based, communication-centered model is the one that will ultimately prove more effective in furthering the growth of radiology, cultivating relationships with our subspecialty referrers that serve as fodder for creating new imaging techniques, and for discovering new imaging findings and patterns that are specific to accepted orthopedic injuries.

Radiology, as a specialty, is fluid, and frequently redirected by advances in technology as well as the needs of its referral base. In orthopedic imaging, the most effective radiologists will be those who not only recognize the salient imaging findings, but who also speak the language of the referrers. This variation on the above communication theme is one I have taken from mentors including Bill Morrison and John Carrino, who encourage, and even insist, that we stay current with the orthopedics and sports medicine literature so that we may tailor our reports to the specific questions asked or implied by our referrers. Our musculoskeletal fellowship curriculum at Jefferson includes a monthly journal club to review pertinent articles from outside of the radiology literature in publications such as the Journal of Bone and Joint Surgery, Clinical Orthopedics, and the American Journal of Sports Medicine, so that we may explore topics pertinent to our clinician referral base. We also work diligently to schedule and participate in numerous musculoskeletal radiology/ orthopedics/ sports medicine interdepartmental conferences where we have the opportunity to openly discuss current musculoskeletal pathologies, their imaging findings, and possible treatment algorithms, with both surgical and nonoperative referrers. These sessions and, more specifically, some of the discussions occurring during and after these sessions, served as the impetus for this issue of Seminars in Musculoskeletal Radiology.

As a relatively junior member of the musculoskeletal radiology community, I have been attending our subspecialty sessions at national and international meetings for only a few years. Even so, I have greatly enjoyed the spirited discussions that spontaneously occur at proceedings, such as the Society of Skeletal Radiology annual meeting, after presentation of new imaging techniques or new patterns of imaging findings. It is clear in these instances how we are driven by our referral base, as topics that might be construed as new to radiologists are simply a manifestation of our understanding of a condition that is not new at all in the orthopedics literature, and subsequently recognizing and describing its MRI or ultrasound appearance. For careful examination of the imaging findings almost always ultimately adds something to the understanding of the disease process itself. In this manner, our relationship with subspecialty referrers should be symbiotic and cyclical, and our subspecialties should continue to grow and prosper together. For this issue, I hoped to solicit articles from some of my fellow junior members of the musculoskeletal community that review the current science surrounding some of these ‘hot topics’ important to both bone radiologists and their orthopedic referrers. But I also asked each author to explore proven and unproven theories as to the role played by imaging in the diagnosis and treatment of these pathologic conditions, and to offer personal insight on which of these theories are most likely to be proven true and why, based on the author's individual experience. In this sense, I hope this set of review articles serves as a sort of template for some of the meaningful interdepartmental radiology-orthopedics research to come in the next decade. Lofty aspirations, no doubt, but I do believe we have succeeded in presenting a group of articles that will update the reader on state-of-the-art imaging findings and imaging techniques as well as spur some introspection and reflection as to how the accepted imaging patterns help us understand the true pathoetiologies of these relatively common musculoskeletal conditions.

No orthopedic topic has been more ‘hot’ over the past 3 years than femoroacetabular impingement (FAI), and Ara Kassarjian was the principle author of the scientific article that gave us the MR arthrographic findings in cam type FAI. In this issue, my former chief resident provides us with an update on the evolution of both the biomechanical science and the imaging of hip pain in the young adult. Eoin Kavanagh, a Jefferson bone fellowship alumnus, now on staff at the University of Pittsburgh Medical Center, teamed-up with colleagues from his hometown of Dublin, Ireland, including my first musculoskeletal radiology mentor, Steve Eustace, to give us an overview of the increasingly complex subject of groin pain in the athlete. Another of our previous bone fellows, Holly Gil, and her colleagues at Brown University, explore a group of pathologies that would be essentially impossible to diagnose without MRI including SONK, transient osteoporosis of the hip, and other causes of subchondral bone marrow edema. Angela Gopez reflects on her four years as the musculoskeletal radiologist for an extremely busy orthopedic surgery service at Naval Medical Center Portsmouth in Virginia to offer us a review of knee meniscal and articular cartilage treatment options and an overview of imaging the knee after meniscal and cartilage surgeries. Jamie (William J.) Malone completed our bone fellowship recently and is now on staff and heading the musculoskeletal section at a large orthopedics center in north-central Pennsylvania. He uses these abundant resources to tackle the ever-elusive concept of injuries involving the posterolateral corner of the knee. Doug Beall is probably the most-senior and definitely the most-published lead author in this issue. He and his colleagues from the University of Oklahoma contribute a comprehensive review of the anatomy and physiology of the rotator cuff interval, as well as insight into imaging its various pathologies.

I am extremely grateful to all the contributing authors who helped bring this issue to fruition. I would also like to thank my numerous mentors in musculoskeletal radiology, some of whom are mentioned above and many others, too many to list, for ‘showing me the ropes’ a bit and for offering me so many opportunities over the past five years. Finally, I would like to express my thanks to the orthopedics and sports medicine subspecialists here in Philadelphia who drive our collaborative efforts and push us to provide more efficient service in imaging of the musculoskeletal system. I hope you all enjoy our submission.