Osteoporosis and bone morbidity in cardiac transplant recipients.

PURPOSE: To evaluate the incidence and etiology of osteopenia and pathologic fractures in cardiac transplant recipients. PATIENTS: Thirty-one adult male cardiac transplant recipients and 14 adult men with congestive heart failure (CHF) awaiting cardiac transplantation. METHODS: Assessment of indices of bone and mineral metabolism and of bone mineral density (BMD) by dual-energy x-ray absorptiometry. RESULTS: BMD in the proximal femur was below normal in both groups compared to that in age-matched control subjects, whereas BMD in the lumbar spine was normal. There was no significant difference in BMD at any site between the two groups. No clinical parameter predicted BMD. In all patients, laboratory indices of bone mineral metabolism, except parathyroid hormone (PTH) levels, were normal and not statistically different between the two groups. CHF patients had a trend toward elevations of PTH, 1,25-dihydroxyvitamin D, and urinary calcium excretion compared to transplant patients. Eight of 31 transplant patients and 2 of 14 CHF patients had vertebral compression fractures (c2 = 11.8, p < 0.0006). Transplant recipients with fractures had twice as many rejection episodes as did transplant patients without fractures, but did not differ in cumulative dose of steroids. Two patients developed avascular necrosis of the femoral head following transplantation. CONCLUSIONS: Cardiac transplant recipients and patients with CHF awaiting transplantation had decreased hip BMD, but normal spine BMD. Although immunosuppressive therapy did not appear to influence bone mass, loop diuretics prior to transplantation may have stimulated a mild secondary increase in PTH that could have differentially caused loss of bone density at the hip in both groups. Pulse corticosteroids used in treating rejection may have contributed to the increased incidence of vertebral fractures in transplant patients. These data suggest that severe CHF with its associated diuretic use and decreased activity are primary contributors to osteopenia in these patients.

Magnetic resonance imaging of the hip with emphasis on avascular necrosis.

The hip has a primary role in weight bearing and gait. It is frequently involved in mechanical and inflammatory processes, leading to a painful joint. The pain is often nonspecific, requiring imaging studies for evaluation and diagnosis. Standard radiographs usually are the initial and often the only study required. Routine radiographs are insensitive to changes in the soft tissues and may not reveal changes in the medullary canal. The multiplanar capabilities and high contrast resolution of magnetic resonance imaging make it an ideal method for imaging the hip following standard radiography. Magnetic resonance imaging may be used to detect abnormalities in patients who have had normal radiographs or it can be used to evaluate the complications or stages of disease in patients who have had abnormal radiographs.

Hypertrophic osteoarthropathy as indication of aortic graft infection and aortoenteric fistula.

Diagnosis of an infected bifurcation graft or aortoenteric fistula can be extremely difficult, and delay in diagnosis may lead to the lethal complication of a ruptured aortoenteric fistula. Hypertrophic osteoarthropathy limited to the lower extremities was the initial symptom of aortoenteric fistula in two of our patients with infected aortic bifurcation grafts. Review of the literature discovered six additional patients with a similar diagnosis, indicating its possible value as an early diagnostic sign of aortoenteric fistula.

Imaging of arthropathies. Crystal disease.

The crystalline arthropathies are a heterogeneous group of biochemical disorders that share the common feature of crystal deposition in and around joints. These metabolic derangements result in a variety of clinical symptoms, radiographic signs, and pathologic abnormalities. The diagnosis of these disorders usually is straightforward when typical articular symptoms are present and characteristic radiographs or joint crystals are obtained. Current concepts regarding crystal-associated arthropathies are reviewed along with a discussion of their often distinctive radiographic appearances.

Advances in spinal imaging.

Considerable technical advances in spinal imaging have been made that have greatly aided diagnosis, surgical planning, treatment, and posttreatment follow-up of patients with spinal disorders. This article presents an update on the recent advances in magnetic resonance, digital, and radionuclide imaging techniques, three-dimensional computed tomography, and sonography of the spine.

Occupational and post-traumatic arthritis.

Secondary osteoarthritis (OA) may result from a number of causes including trauma or may be related to a specific occupation or activity. In patients who present with atypical OA one should consider the possibility of such an etiology. This article discusses post-traumatic osteoarthritis and specific forms of occupational OA.

MR imaging of the wrist.

The use of MR imaging in the area of the wrist has lagged due to the technical challenges posed by the small size of the structures of the wrist. After a careful history, physical examination, and plain films, MR imaging is a powerful next imaging study for solving diagnostic problems involving this complex region. The increasing ability of MR imaging to diagnose wrist abnormalities noninvasively has led to a decrease in the use of invasive techniques.

Wrist arthrography.

Wrist arthrography is an adjunctive procedure that may be valuable to the clinician. Although it is sensitive to particular abnormalities, it lacks the specificity to completely diagnose a given condition. Information gained by arthrography can be used a supportive evidence, in conjunction with clinical and laboratory findings, to aid in the management of individual patients.

Computed tomography of musculoskeletal trauma.

Radiology plays a crucial role in the evaluation of the acutely traumatized patient by providing information that allows timely and appropriate management to be instituted. With few exceptions, notably the skull, plain films remain the primary imaging technique for the diagnosis of skeletal trauma. Computed tomography (CT) has become an important adjunctive procedure in the evaluation and diagnosis of trauma, particularly in complex anatomic areas, including the sternoclavicular joint, the pelvis, and the spine, and in many hospitals has virtually replaced conventional tomography. It may be combined with arthrography or enhanced by intravenous or intrathecal contrast material. This article reviews the uses of CT in the diagnosis and evaluation of musculoskeletal trauma and its complications.

Imaging of the knee.

MR imaging has become the primary imaging modality of the knee. Its advantages include its noninvasive nature, multiplanar imaging capability, excellent soft-tissue contrast, and high resolution. The need for multiple imaging modalities is obviated, as the menisci, cruciate ligaments, synovium, articular cartilage, marrow, and periarticular soft tissues can be simultaneously evaluated. Other imaging modalities may occasionally be helpful in the evaluation of specific problems including CT in tibial plateau fractures, real-time ultrasound for the confirmation of a popliteal cyst or popliteal artery aneurysm, and arthrography for the detection of prosthetic joint loosening.

The use of magnetic resonance imaging in the evaluation of bone and soft-tissue tumors.

We believe that MR imaging should follow plain films in the imaging analysis of soft-tissue tumors and bone tumors suspected of malignancy. MR imaging is primarily useful in tumor staging, although it may aid in diagnosis and the detection of recurrent or residual disease. Gd-DTPA and MR spectroscopy are currently being evaluated in many medical centers; their utility in the work-up and management of tumors of bone and soft tissue has yet to be determined.

Strategies for musculoskeletal magnetic resonance imaging.

There is a broad range of clinical applications for MRI in the diagnosis of musculoskeletal disease, and the emphasis in this article is on the evaluation of the joints and extremities. A discussion of basic principles, including radiofrequency coils, positioning, pulsing sequences, imaging planes, and technical parameters is followed by discussions of tailored approaches to the evaluation of mass lesions and joint pathology for specific regions of the musculoskeletal system. In the final section, consideration is given to the overall role of MRI in the diagnosis of musculoskeletal disorders with respect to other established imaging modalities.

Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value.

The sensitivity, specificity, and predictive value of magnetic resonance imaging in the diagnosis of lesions of the rotator cuff, glenohumeral capsule, and glenoid labrum were evaluated in ninety-one patients and fifteen asymptomatic volunteers. Magnetic resonance imaging demonstrated 100 per cent sensitivity and 95 per cent specificity in the diagnosis of complete tears, and it consistently predicted the size of the tear of the rotator cuff. There was a definite correlation between atrophy of the supraspinatus muscle and the size of a complete, chronic tear of the rotator cuff. The sensitivity and specificity of magnetic resonance imaging in the differentiation of tendinitis from degeneration of the cuff were 82 and 85 per cent, and in the differentiation of a normal tendon from one affected by tendinitis with signs of impingement the sensitivity and specificity were 93 and 87 per cent. The formation of spurs around the acromion and acromiocalvicular joint correlated highly with increased age of the patient and with chronic disease of the rotator cuff. The sensitivity and specificity of magnetic resonance imaging in the diagnosis of labral tears associated with glenohumeral instability were 88 and 93 per cent. The study showed that high-resolution magnetic-resonance imaging is an excellent non-invasive tool in the diagnosis of lesions of the rotator cuff and glenohumeral instability.

Posttraumatic changes in the posterior glenoid and labrum in a handball player.

Magnetic resonance imaging evaluation of a handball player with chronic pain in his nondominant shoulder revealed posttraumatic changes in the posterior glenoid and labrum. This provided a pathophysiologic explanation for the patient's symptoms.

Magnetic resonance imaging of the postoperative shoulder.

The use of MR imaging in the evaluation of the postoperative shoulder and the findings indicative of postoperative pathology remain largely unexplored. MR imaging does seem to be diagnostic of complete rotator cuff tears following cuff repair. In all postoperative cases, a key to differentiating the expected from the pathologic is to be familiar with the procedure that was performed.

Imaging of the elbow. An update.

This article focuses on the use of magnetic resonance in the evaluation of the soft tissue (tendons, ligaments, muscles, and nerves) and osseous structures of the elbow. The need for high quality, high resolution imaging with attention to positioning, sequence selection, and equipment is emphasized. Normal magnetic resonance anatomy and criteria for pathologic change are presented.

Magnetic resonance imaging of the shoulder.

The shoulder is now accessible to MRI owing to recent technical advances. The major advantages of this modality include its noninvasive nature, lack of ionizing radiation, excellent contrast and anatomic resolution, multiplanar imaging capability, and ability as a single imaging modality to evaluate simultaneously for a wide variety of pathologic processes. It is proving its utility particularly in the evaluation of the painful shoulder and the diagnosis of glenohumeral instability, rotator cuff impingement, tendinitis, and tear. We believe that with greater experience and large comparative studies, MRI will clearly demonstrate its superiority in evaluation of the shoulder and will almost entirely replace arthrography, as has occurred with the knee.

CT in pelvic trauma.

The use of computed tomography is extremely important in the care of patients with pelvic trauma. We believe that it should be performed on all patients with severe pelvic injury. It depicts the pelvic anatomy in exquisite detail, enabling one to plan therapy on the basis of pathologic anatomy rather than the presumed mechanism of injury. CT is more expensive than tomography but gives considerably more information at a lower radiation dose. It is also of considerable value in postoperative follow-up for determination of the adequacy of reduction and fracture healing.

Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures.

OBJECTIVE: To evaluate the interobserver and intraobserver agreement for both treatment plan and fracture classification of tibial plateau fractures using plain films alone and with computed tomography (CT) scans. DESIGN: Prospective study to assess the impact of an advanced radiologic study on the agreement of treatment plan and fracture classification of tibial plateau fractures. SETTING/PARTICIPANTS: Two orthopaedic traumatologists, two orthopaedic residents, and two skeletal radiologists were presented with twenty-one cases of tibial plateau fractures imaged with plain films and with CT scans. MAIN OUTCOME MEASURES: Agreement was measured using kappa coefficients. RESULTS: Using plain films alone, the mean interobserver kappa coefficient for classification was 0.62, which decreased to 0.61 after addition of CT scans. Using plain films alone for formulating a treatment plan, the mean interobserver kappa coefficient was 0.58, which increased to 0.71 after addition of CT scans. The mean intraobserver kappa coefficient for fracture classification using plain films was 0.70, which increased to 0.80 with addition of CT scans. The mean intraobserver kappa coefficient for treatment plan based on plain films alone was 0.62, which increased to 0.82 after addition of CT scans. Class was changed in an average of 12 percent of cases after addition of CT scans. Treatment plan was changed an average of 26 percent of the time after addition of CT scans. CONCLUSION: Addition of CT scans to plain roentgenograms increases the interobserver and intraobserver agreement on treatment plan.

The radiographic evaluation of spinal trauma.

The authors describe a systematic approach to the radiographic evaluation of spinal trauma, discussing cervical spine anatomy, the mechanism of injury, and classification of injuries, and then discuss several specific injuries of the cervical and thoracolumbar spine and their radiographic evaluation.