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Varicose veins are associated with conditions that impair venous return, such as pregnancy, physical inactivity, valve failure and post-thrombotic syndrome. We report the case of a 50-year-old female patient with history of intermittent calf pain, worsening with prolonged standing posture. She had no previous medical history of either lower extremity trauma or infection. Physical examination showed medial pretibial soft tissue swelling. CT and MRI showed images suggestive of anomalous intraosseous venous drainage with associated bone edema and periosteal reaction. Knowledge of this rare entity is fundamental for proper patient management.

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Scapulothoracic dislocation (STD) is a rare condition consisting in the loss of anatomical relations of the scapula with the posterior chest wall. This pathological condition commonly occurs after a scapular region trauma or an upper arm distractive injury. Here-in, we present a case of STD occurring in a young male patient, and we discuss the mechanism of injury, the radiological imaging features, and how it can guide and help the orthopedist in the management.

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OBJECTIVES: Recurrent monoarthritis (RM) is a major challenge of many rheumatic diseases. Ablation is a well-known technique in the treatment of benign or malign lesions of different etiologies. We aimed to to investigate the success and safety of microwave ablation (MWA) as an adjunctive therapy in a cohort of medical treatment-resistant RM. METHODS: Patients with RM associated with different inflammatory diseases were included. MWA was performed after measuring the size of synovial hypertrophy with 15 or 20-watt power and different durations until microbubbles were shown indicating necrosis. Both clinical and radiologic data were recorded. RESULTS: We applied MWA in total of 24 knee joints of 10 female and 12 male patients aged between 22-71 years. Median intra-articular aspiration (IAA) need in the last 6 months before MWA was 5 (0-15). The median follow-up was 10 (3-16) months. Overall IAA count in the last 6 months before MWA in total of 144 months was 129 and decreased to 7 in post-MWA in total of 226 months (0.89 vs 0.03 per month, p< 0.001). The second MWA session was needed for 3 patients and a third session for 1. Functional disability and pain scores were improved significantly (median score from 9 to 1, p< 0.00001, in both). In magnetic resonance imaging, follow-up significant regression in synovial hypertrophy size was shown especially after 6th month. No complication was observed during the procedure or follow-up. CONCLUSION: As a less invasive technique compared with the surgical approach, MWA of synovial hypertrophy showed significant clinical improvement in RM safely. MWA seems promising as a treatment option candidate in the management of RM.

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Introduction: Pelvic apophyseal avulsion fractures are uncommon injuries that frequently affect adolescents while participating in sports. This occurs because the enthesis cannot withstand the tractional force applied because the apophysis has not yet fully fused. Due to its complex muscular structure, being the origin of several muscles that cross two lower extremity joints, the pelvis has an increased risk for such injuries. The diagnosis of pelvic avulsion injuries depends heavily on imaging. The best way to detect soft-tissue changes, including tendon or muscle strain, bone marrow edema, hematomas, and soft tissue avulsion injuries, is with an magnetic resonance imaging . It is also the best at showing tendon retraction and can help the clinician spot patients who might benefit from surgical treatment. Case Report: We report six cases of adolescents professional footballers that suffered avulsion injuries while playing football. The patients had painfully restricted hip range of motion and were unable to bear weight. Some of them on physical examination felt pain at the palpation of the injured area. Magnetic resonance revealed apophysis growth plate avulsion with or without displaced bone fragments that were treated conservatively with an excellent clinical and radiological outcome. Conclusion: For an accurate diagnosis of pelvic avulsion injuries and clinical management, it is important that everyone caring for this patient population is aware of the common injury mechanisms, radiographic findings, and available treatments.

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The first years of an academic musculoskeletal (MSK) faculty position are a time of transition for the junior faculty member, who must rapidly adjust to new clinical, academic, operational, and professional responsibilities. Mentoring has a critical role in helping the faculty member to thrive in these early years. Establishing clear communication, trust, and expectations can set the foundation for an effective mentoring relationship. Junior faculty members ideally would have multiple mentors with different areas of expertise, including mentors of all roles in MSK radiology but also in other radiology divisions and other departments. Private practice MSK radiologists can also benefit from mentorship. Barriers to mentoring in MSK radiology include overall smaller division sizes, a newer and smaller field on a national level, and the increase in clinical volume and remote work that results in less face-to-face interaction. Despite the challenges, both junior MSK faculty members and their mentors can benefit greatly from strong mentoring connections.

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Saliency maps are popularly used to "explain" decisions made by modern machine learning models, including deep convolutional neural networks (DCNNs). While the resulting heatmaps purportedly indicate important image features, their "trustworthiness," i.e., utility and robustness, has not been evaluated for musculoskeletal imaging. The purpose of this study was to systematically evaluate the trustworthiness of saliency maps used in disease diagnosis on upper extremity X-ray images. The underlying DCNNs were trained using the Stanford MURA dataset. We studied four trustworthiness criteria-(1) localization accuracy of abnormalities, (2) repeatability, (3) reproducibility, and (4) sensitivity to underlying DCNN weights-across six different gradient-based saliency methods (Grad-CAM (GCAM), gradient explanation (GRAD), integrated gradients (IG), Smoothgrad (SG), smooth IG (SIG), and XRAI). Ground-truth was defined by the consensus of three fellowship-trained musculoskeletal radiologists who each placed bounding boxes around abnormalities on a holdout saliency test set. Compared to radiologists, all saliency methods showed inferior localization (AUPRCs: 0.438 (SG)-0.590 (XRAI); average radiologist AUPRC: 0.816), repeatability (IoUs: 0.427 (SG)-0.551 (IG); average radiologist IOU: 0.613), and reproducibility (IoUs: 0.250 (SG)-0.502 (XRAI); average radiologist IOU: 0.613) on abnormalities such as fractures, orthopedic hardware insertions, and arthritis. Five methods (GCAM, GRAD, IG, SG, XRAI) passed the sensitivity test. Ultimately, no saliency method met all four trustworthiness criteria; therefore, we recommend caution and rigorous evaluation of saliency maps prior to their clinical use.

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This narrative review explores recent advancements and applications of modern low-field (≤ 1 Tesla) magnetic resonance imaging (MRI) in musculoskeletal radiology. Historically, high-field MRI systems (1.5 T and 3 T) have been the standard in clinical practice due to superior image resolution and signal-to-noise ratio. However, recent technological advancements in low-field MRI offer promising avenues for musculoskeletal imaging. General principles of low-field MRI systems are being introduced, highlighting their strengths and limitations compared to high-field counterparts. Emphasis is placed on advancements in hardware design, including novel magnet configurations, gradient systems, and radiofrequency coils, which have improved image quality and reduced susceptibility artifacts particularly in musculoskeletal imaging. Different clinical applications of modern low-field MRI in musculoskeletal radiology are being discussed. The diagnostic performance of low-field MRI in diagnosing various musculoskeletal pathologies, such as ligament and tendon injuries, osteoarthritis, and cartilage lesions, is being presented. Moreover, the discussion encompasses the cost-effectiveness and accessibility of low-field MRI systems, making them viable options for imaging centers with limited resources or specific patient populations. From a scientific standpoint, the amount of available data regarding musculoskeletal imaging at low-field strengths is limited and often several decades old. This review will give an insight to the existing literature and summarize our own experiences with a modern low-field MRI system over the last 3 years. In conclusion, the narrative review highlights the potential clinical utility, challenges, and future directions of modern low-field MRI, offering valuable insights for radiologists and healthcare professionals seeking to leverage these advancements in their practice.

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PURPOSE: Clinical cone-beam computed tomography (CBCT) devices are limited to imaging features of half a millimeter in size and cannot quantify the tissue microstructure. We demonstrate a robust deep-learning method for enhancing clinical CT images, only requiring a limited set of easy-to-acquire training data. METHODS: Knee tissue from five cadavers and six total knee replacement patients, and 14 teeth from eight patients were scanned using laboratory CT as training data for the developed super-resolution (SR) technique. The method was benchmarked against ex vivo test set, 52 osteochondral samples are imaged with clinical and laboratory CT. A quality assurance phantom was imaged with clinical CT to quantify the technical image quality. To visually assess the clinical image quality, musculoskeletal and maxillofacial CBCT studies were enhanced with SR and contrasted to interpolated images. A dental radiologist and surgeon reviewed the maxillofacial images. RESULTS: The SR models predicted the bone morphological parameters on the ex vivo test set more accurately than conventional image processing. The phantom analysis confirmed higher spatial resolution on the SR images than interpolation, but image grayscales were modified. Musculoskeletal and maxillofacial CBCT images showed more details on SR than interpolation; however, artifacts were observed near the crown of the teeth. The readers assessed mediocre overall scores for both SR and interpolation. The source code and pretrained networks are publicly available. CONCLUSION: Model training with laboratory modalities could push the resolution limit beyond state-of-the-art clinical musculoskeletal and dental CBCT. A larger maxillofacial training dataset is recommended for dental applications.

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PURPOSE: Ongoing quality improvement (QI) processes in the authors' department include the insertion of a Kellgren-Lawrence (KL) osteoarthritis grading template in knee radiography reports to decrease unnecessary MRI. However, uniform adoption of this grading system is lacking. Department-wide financial incentives were instituted to improve compliance with QI metrics. The purpose of this study was to evaluate the effect of a financial incentive on KL grading system use and to compare compliance rates of musculoskeletal (MSK) radiologists with those of general radiologists who were not financially incentivized to use KL grading. METHODS: Percentages of all knee radiography reports containing KL grading with standardized follow-up recommendations were determined by querying the departmental radiology database before and after the introduction of the new quality-based financial incentive. Preincentive compliance rates for MSK and general radiologists were compared with an adoption period and two separate 6-month postincentive periods. RESULTS: In total, 52,673 reports were retrospectively analyzed for KL grading use (41,670 reports interpreted by MSK radiologists and 11,003 interpreted by general radiologists). Increase in compliance was greatest among MSK radiologists' reports during the incentivized adoption period (from 36.1% to 53.2%). This improvement was sustained among MSK radiologists and averaged 62.7% during the most recently studied postimplementation period. A lesser degree of improvement in compliance was observed in nonincentivized general radiologists' reports (from 19.3% to 27.5%); during the postimplementation follow-up period, their compliance decreased to 26.5%. CONCLUSIONS: The introduction of a financial incentive resulted in significantly increased adoption of QI practices with sustained improvement among incentivized MSK radiologists compared with nonincentivized general radiologists.

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Rheumatoid arthritis (RA) is a chronic, inflammatory systemic disorder of synovial joints and results in polyarthritis, chronical degeneration, and finally deformities and ankylosis in severe cases. Synovitis and pannus formation are results of inflammatory changes and lead into restriction in joint movement. Shoulders are among the later affected and larger joints and formation of synovitis in early active stages and pannus in later stages might be concluded with frozen shoulder and severe impairment in functionality. These late-term changes cannot be controlled with systemic or local anti-inflammatory agents and synovectomy is chosen in some cases. However, the results are not satisfactory and recurrence is common. In this case report, we presented a case of RA with severe shoulder pain, restricted movement due to synovial hypertrophy, and pannus formation which are resistant to local and systemic interventions and not suitable for surgical or chemical synovectomy. Microwave ablation (MWA) was performed successfully without any complication and she well responded in terms of DAS-28, functional, and pain scores. Range of motion and funcitonal restriction were recovered. This case report describes the use and promising results of MWA in RA with severe synovial hypertrophy and pannus formation even in the absence of active arthritis and effusion. MWA is a safe and minimally invasive technique that can be easily performed in coordinance of rheumatologists and interventional radiologists in proper cases.

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OBJECTIVE: To better understand the current state of musculoskeletal fellowship program directors and identify opportunities for formal training that could increase job satisfaction, provide a broader knowledge base for mentoring/advising trainees and increase diversity in musculoskeletal radiology. MATERIALS AND METHODS: Eighty-one fellowship program directors who signed the Fellowship Match Memorandum of Understanding with the Society of Skeletal Radiology were sent a survey with questions about demographics, career, background, and training both for musculoskeletal radiology and for the fellowship director role. RESULTS: A 57/81 (70%) of program directors responded, representing 27 different states with a range of 1-9 fellowship positions. Nearly half are in their forties (48%) with most identifying as White (67%) followed by Asian (30%). The majority are male (72%) with over half (60%) remaining at the institution where they completed prior training. Over half plan to change roles within 5 years and do not feel adequately compensated. Top qualities/skills identified as important for the role include effective communication, being approachable, and clinical excellence. Other than clinical excellence, most do not report formal training in skills identified as important for the role. CONCLUSIONS: Given the high amount of interaction with trainees, program directors play a key role in the future of our subspecialty. The low diversity among this group, the lack of formal training, and the fact that most do not feel adequately compensated could limit mentorship and recruitment. Program directors identified effective communication, organizational/planning skills, and conflict resolution as the top skills they would benefit from formal training.

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BACKGROUND: Deep learning (DL) can improve image quality by removing noise from accelerated MRI. OBJECTIVE: To compare the quality of various accelerated imaging applications in knee MRI with and without DL. METHOD: We analyzed 44 knee MRI scans from 38 adult patients using the DL-reconstructed parallel acquisition technique (PAT) between May 2021 and April 2022. The participants underwent sagittal fat-saturated T2-weighted turbo-spin-echo accelerated imaging without DL (PAT-2 [2-fold parallel accelerated imaging], PAT-3, and PAT-4) and with DL (DL with PAT-3 [PAT-3DL] and PAT-4 [PAT-4DL]). Two readers independently evaluated subjective image quality (diagnostic confidence of knee joint abnormalities, subjective noise and sharpness, and overall image quality) using a 4-point grading system (1-4, 4=best). Objective image quality was assessed based on noise (noise power) and sharpness (edge rise distance). RESULTS: The mean acquisition times for PAT-2, PAT-3, PAT-4, PAT-3DL, and PAT-4DL sequences were 2:55, 2:04, 1:33, 2:04, and 1:33 min, respectively. Regarding subjective image quality, PAT-3DL and PAT-4DL scored higher than PAT-2. Objectively, DL-reconstructed imaging had significantly lower noise than PAT-3 and PAT-4 (P <0.001), but the results were not significantly different from those for PAT-2 (P >0.988). Objective image sharpness did not differ significantly among the imaging combinations (P =0.470). The inter-reader reliability ranged from good to excellent (κ = 0.761­0.832). CONCLUSION: PAT-4DL imaging in knee MRI exhibits similar subjective image quality, objective noise, and sharpness levels compared with conventional PAT-2 imaging, with an acquisition time reduction of 47%.

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Voriconazole-induced periostitis (VIP) is an uncommon side effect typically seen in immunosuppressed patients requiring prolonged antifungal therapy. These patients can present with bone pain, fragility, and elevated alkaline phosphatase (ALP). We present a case of VIP in a 72-year-old immunocompromised female on antifungal therapy presenting with a comminuted intertrochanteric fracture after a ground-level fall. VIP, although rare, should be included as a differential diagnosis for patients presenting with bone pain and/or fractures with radiographic features of periostitis. This is particularly true when there is a history of or prior imaging suggesting a solid organ transplant. In these cases, a dedicated review of current medications noting long-term voriconazole use in the absence of underlying rheumatologic disease can result in a confident diagnosis.

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The rapid evolution of artificial intelligence (AI) in medical imaging analysis has significantly impacted musculoskeletal radiology, offering enhanced accuracy and speed in radiograph evaluations. The potential of AI in clinical settings, however, remains underexplored. This research investigates the efficiency of a commercial AI tool in analyzing radiographs of patients who have undergone total knee arthroplasty. The study retrospectively analyzed 200 radiographs from 100 patients, comparing AI software measurements to expert assessments. Assessed parameters included axial alignments (MAD, AMA), femoral and tibial angles (mLPFA, mLDFA, mMPTA, mLDTA), and other key measurements including JLCA, HKA, and Mikulicz line. The tool demonstrated good to excellent agreement with expert metrics (ICC = 0.78-1.00), analyzed radiographs twice as fast (p < 0.001), yet struggled with accuracy for the JLCA (ICC = 0.79, 95% CI = 0.72-0.84), the Mikulicz line (ICC = 0.78, 95% CI = 0.32-0.90), and if patients had a body mass index higher than 30 kg/m2 (p < 0.001). It also failed to analyze 45 (22.5%) radiographs, potentially due to image overlay or unique patient characteristics. These findings underscore the AI software's potential in musculoskeletal radiology but also highlight the necessity for further development for effective utilization in diverse clinical scenarios. Subsequent studies should explore the integration of AI tools in routine clinical practice and their impact on patient care.

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During medical image analysis, it is often useful to align (or 'normalize') a given image of a given body part to a representative standard (or 'template') of that body part. The impact that brain templates have had on the analysis of brain images highlights the importance of templates in general. However, templates for human hands do not exist. Image normalization is especially important for hand images because hands, by design, readily change shape during various tasks. Here we report the construction of an anatomical template for healthy adult human hands. To do this, we used 27 anatomically representative T1-weighted magnetic resonance (MR) images of either hand from 21 demographically representative healthy adult subjects (13 females and 8 males). We used the open-source, cross-platform ANTs (Advanced Normalization Tools) medical image analysis software framework, to preprocess the MR images. The template was constructed using the ANTs standard multivariate template construction workflow. The resulting template image preserved all the essential anatomical features of the hand, including all the individual bones, muscles, tendons, ligaments, as well as the main branches of the median nerve and radial, ulnar, and palmar metacarpal arteries. Furthermore, the image quality of the template was significantly higher than that of the underlying individual hand images as measured by two independent canonical metrics of image quality.

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Intramedullary osteosclerosis (IMOS) is a rare process of intramedullary bone formation in one or more bones in the lower limb. It arises in adulthood, its etiology is unknown, and it is diagnosed by exclusion. We present a case of a 26-year-old female who presented with three-week history of right tibial pain provoked by prolonged standing. Imaging revealed sclerotic cortical thickening, in addition to sclerosis at the mid-tibial segment. Intramedullary osteosclerosis is an uncommon cause of leg pain. The literature revealed that non-steroidal anti-inflammatory drugs (NSAIDs) might be of use to help ease the pain.

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Magnetic resonance imaging (MRI) is essential for assessing shoulder conditions. This study aimed to evaluate current shoulder MRI practices in Jordan, including technical parameter patterns, and determine if they adhere to the American College of Radiology (ACR) guidelines. The retrospective analysis included data from 48 eligible participants from 13 MRI centers in March 2021. Descriptive and correlation data analysis were performed using IBM SPSS statistics version_20 and Excel 2013. Most MRI centers (50%) were private outpatient clinics with closed MRI machines above 1 Tesla. Most participants (62.5%) were male, and shoulder pain (47.9%) was the main clinical indication. Most shoulder orientations (68.7%, 33/48) were right shoulders, and the coronal MRI planes (43%, 121/280) were the most common. The alignment percentage for the axial plane was 100%, but MRI artifacts of the shoulder were present in 8.2% of cases (23/280). Dark fluid T1-W coronal sequence was not conducted in 25% of the cases. The percentage of the field view (FOV) within ACR recommendations was 45% (126/281), and slice thickness parameters were 96% (269/281). The recommended pixel area for all sequences was 47.9% (134/280), encompassing all axial, sagittal oblique, and coronal planes. However, crucial parameters, such as FOV and slice thickness, were inadequate and did not meet the ACR guidelines, resulting in suboptimal image quality of shoulder MRI. To improve MRI image quality, it is recommended that MRI technologists receive ongoing education and training on appropriate MRI image parameters.

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PURPOSE: Digital templating using pre-operative radiographs enables pre-operative planning for total hip arthroplasty (THA). This allows surgeons to reproduce hip biomechanics effectively, reducing the risk of post-operative complications. Pelvic radiographs demonstrating the head, neck, trochanters, and proximal one-third of the femoral shaft allow calculation of key measurements including femoral offset and limb length discrepancy (LLD). Currently, no standardised guideline exists for obtaining pre-operative radiographs for templating in THA.  Materials and methods: A single-blinded retrospective cohort study assessing the quality of pre- and post-operative radiographs of 195 patients who underwent elective THA for osteoarthritis over a two-year period was performed. Quality was rated as good, fair or poor, respectively, depending upon whether ≥2, 1 or none of the following were met: Pubic symphysis (PS) and coccyx in a straight line with 1-3 cm between the superior edge of the PS and tip of coccyx, trochanters distinguishable, obturator rings symmetric. Post-operative images were assessed to determine whether the distal end of the implanted prosthesis was visible.  Results: The sample consisted of 195 patients. Pre-operatively 115 (59%) radiographs were classified as good, 71 (36.4%) fair and 9 (4.6%) poor. Post-operatively 46 (23.6%) were classified as good, 114 (58.4%) as fair and 30 (15.4%) as poor. In the post-operative radiographs, 25.6% did not include the distal tip of the prosthesis.  Conclusion: This study highlights significant scope to improve the quality of pre-operative radiographs, allowing accurate templating to optimise outcomes for THA. A protocol is recommended whereby the pelvic radiograph is centred on the PS at the lesser trochanter level, ensuring adequate exposure of the proximal femur, acetabulum and iliac crests.

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BACKGROUND: Our aim was to understand how musculoskeletal training is structured in Italian residency programmes and the needs of young trainees. METHODS: We sent out an online questionnaire (17 questions) to Italian Society of Radiology residents and board-certified radiologists aged up to 39 years. RESULTS: A total of 1144 out of 4210 (27.2%) members participated in the survey; 64.7% were residents and 35.3% were board-certified radiologists. Just 26.6% of participants had dedicated rotations for musculoskeletal training during their residency, although this percentage substantially increased in replies from northern Italy. One-fourth of residents had a scheduled period of musculoskeletal ultrasound. Most participants (76.3%) had <20 h per year of musculoskeletal lessons. The majority considered their musculoskeletal education poor (57.7%) or average (21.9%). According to 84.8% of replies, no dedicated training period about interventional musculoskeletal procedures was scheduled. Further, just 12.8% of residents took active part in such interventions. Nearly all participants believed that the musculoskeletal programme during residency needs to be improved, particularly concerning practices in ultrasound (92.8%), MRI cases interpretation/reporting (78.9%), and practice in ultrasound-guided interventional procedures (64.3%). CONCLUSIONS: Despite some differences in the structure of musculoskeletal education provided by different regions, there is a shared demand for improvement in musculoskeletal training.