0:01

Okay, we have some questions.

0:03

Uh, okay. Do you routine perform Abe in arthro? Mr.

0:09

Uh, in what plane do you acquire the image

0:12

and what does it give you compared to the routine planes?

0:16

Uh, okay. So we do,

0:19

whenever possible, we do, when we do an autogram,

0:22

we do include an a a, some patients cannot get into

0:25

that particular, uh, position.

0:28

Um, some people actually are doing a,

0:31

a imaging without an autogram.

0:33

Uh, when they're studying instability in, in any patient,

0:37

they might include a bear.

0:39

And there are, I believe, some reports

0:41

that it can be beneficial, some with the arm over the head.

0:44

You use a foil that's here

0:47

and you project the images along the length of the humerus.

0:51

And the first time you look at the images,

0:53

you can't figure what's up or down.

0:55

And, uh, it does take a while

0:57

and you can't cross reference the images

0:59

because they're done in a different arm position.

1:03

I think it is useful for two major things, particularly if,

1:07

if there's fluid in the joint.

1:09

So we do it with arthrography.

1:11

If the patient has a large effusion on a

1:13

standard MR, you could do it.

1:15

I think it's very good for looking at the undersurface

1:18

of the rotator cuff.

1:20

That's the supra and infra because they're relaxed

1:23

and you'll see more delaminated tears of those tendons.

1:27

And it's good for looking at any problem at the attachment

1:30

sites of the anterior band,

1:32

of the inferior glen malignant better at the glenoid

1:35

attachment site than at the humeral attachment site.

1:39

So it's not just perthes,

1:40

I think it's all the various lesions that we,

1:43

that we talked about.

1:45

I mean, I will say as an experienced practitioner, I,

1:47

you know, I'm embarrassed with some of these a reviews

1:49

that I have to kind of find my way around. Oh,

1:52

No question. And,

1:53

and usually what I'll do is I'll find some structure

1:55

that I know, I know I'll latch onto that structure,

1:58

I'll cross reference it,

1:59

and that, that kind of helps me find my way

2:01

around what's in front,

2:02

what's in back, what's up and what's down.

2:04

Yeah. And that, and for those of you beginning with that,

2:06

I would tell you the best landmark is

2:09

to find the biceps tendon in a groove.

2:12

'cause that's super, you'll see the subscapularis on the

2:16

same image attaching to the lesser.

2:18

So if you find that image

2:20

and that's the top, then you can go down from, uh, from uh,

2:24

there, uh, arthro ct.

2:26

Does it give more definition chondral

2:29

damage in your opinion?

2:31

We don't have a lot of experience. Maybe you do with art ct.

2:35

The images I've seen have been terrific. I think it's good.

2:38

I find they're a little, at least for me, probably

2:41

'cause of lack of experience.

2:42

I have to struggle with them when I, I look at it.

2:45

But I think it can be excellent, uh,

2:49

not just in the glenohumeral joint,

2:51

but you could consider that for, for other joints as well.

2:56

Uh, it's just that we don't, we tend to use Mr.

2:58

Arthrography more often than arthro ct.

3:02

I mean, we use a fair amount of arthro ct

3:05

and I, I, I really like Mr better the ability,

3:08

even without contrast, the ability

3:10

to see into the cartilage.

3:11

As long as you have cartilage sensitive sequences,

3:14

especially something like a a one millimeter, you know,

3:18

merge medic, uh, MFFR, uh, one

3:22

of these additive gradient echo sequences, I find

3:25

that we do extremely well, even with subtle cartilage

3:27

as well or, or better than arthro ct.

3:30

That's interesting. Do you make reference in your reports

3:33

to laxa redundant capsules?

3:35

That's an interesting question.

3:37

The article that came out probably now 20 years,

3:40

I always add about five years when I go back.

3:42

So I'd say it's about 20,

3:44

20 years ago was from the Navy Hospital,

3:47

and they did a series of, uh, patients

3:49

where they injected a known amount of contrast agent, uh,

3:53

in the, uh, in the joint and in axial plane.

3:56

And they may have used the, a bear plane.

3:58

They came up with measurements of what the normal distension

4:02

of the capsule should look like,

4:04

and they were able to identify capsular laxity.

4:08

I think it is difficult with Mr.

4:10

Arthrography because we inject various amounts of,

4:14

uh, contrast material.

4:15

It varies among our fellows.

4:17

So, uh, but you would I eyeball it to be honest.

4:21

I I am, I'm not someone who measures a lot

4:23

of things like Ben Fel. Yeah. He

4:26

Didn't do much measureing. Yeah.

4:27

So, so in any case, uh, I kind of eyeballed

4:31

and see if it looks like it's, it's lax,

4:33

but I don't have any measurements

4:35

that I can give you for that.

4:38

The last question I think is yours.

4:39

Sure. The question is that Dr.

4:41

Pomerance can assists on the posterior margin

4:44

of the humerus, the simply cysts of synovial invagination,

4:49

or do you always associate them with instability?

4:52

Well, I think most of the cysts that you see are,

4:55

are pseudocysts.

4:57

Um, they're either related to, you know, traction

5:01

or, or impaction.

5:03

And I, I think it's a tableau of, of, of both, a mixture

5:07

of both, depending upon the type of instability.

5:10

And as I mentioned earlier, I use them as a roadmap.

5:13

I, you know, I haven't studied them, um, hi histologically,

5:18

so I can't say with certainty that they don't have, uh,

5:21

synovial tissue in them.

5:22

But, uh, I suspect that most of them do not have, uh,

5:26

synovial tissue in them.

5:28

Now, you, the second part

5:29

of your question is do you always associate

5:31

them with instability?

5:32

And the answer is absolutely not.

5:34

Um, patients can be asymptomatic with,

5:37

with shockingly large, uh, cysts

5:41

or pseudocysts in the humeral head.

5:43

Uh, but it should make you at least direct your attention.

5:46

For instance, that large postero superior one that we,

5:50

we have on the screen should direct your attention

5:53

to the infra spd, the postero superior labrum,

5:56

and so on in internal impingement.