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.

Radiography of the distal extremity of the manus in the donkey foal: Normal images and quantitative characterization from birth to 2 years of age: A pilot study.

This study describes a radiographic survey of the anatomical development of the distal extremity of the manus in the donkey from 0 to 2 years of age. The right distal limb of 10 donkey foals, born in the spring of 2012, underwent radiographs every month for the first 6 months of age and every 3 months during the following 18 months. Latero-medial radiographs with and without barium marker at the coronary band and dorso-palmar radiographs with both front feet in weight bearing were obtained. The distal physis of the third metacarpal bone and the proximal physis of the proximal phalanx (phalanx proximalis) were closed at the mean age of 18.6 months. The distal physis of the proximal phalanx appeared as a clear radiolucent line at 2 weeks of age and was still subtly visible in some donkeys at 24 months. The proximal physis of the middle phalanx (phalanx media) was closed at the mean age of 16.7 months. The distal physis of this phalanx was visible at birth, but closed at 4 days. The distal phalanx (phalanx distalis) was triangular at birth. At the age of 20-21 months, the palmar processes (processus palmares) were both developed. The navicular bone (os sesamoideum distalis) was developed at the mean age of 9 months. The proximal sesamoid bones (ossa sesamoidea proximalia) were seen in continuously development during the 24 months. It seems that the physes in the distal extremity of the manus in the donkey close at an older age than the physes in the horse.

Practice variability in the management of subrenal arterial stenoses in seven Belgian hospitals.

This multicentre retrospective study describes the variation of therapeutic options, treatment outcomes and costs for treating subrenal arterial stenoses as observed in daily practice in 1997-99 in seven Belgian hospitals. Data were obtained from clinical record review and from the sickness fund claims database, and included preoperative functional state, presence of acute ischaemia, diabetes and polyvascular disease, state of the lower-leg run-off arteries, anatomical site and type of lesion, type of treatment, result at 30 days and up to 4 years. A total of 442 episodes were studied, but most analyses dealt with a subgroup of 240 lesions in the common iliac up to the superficial femoral artery. The proportion of surgical treatments (as compared to an endovascular or mixed approach) varied from 15% to 81% between the hospitals. In univariate patency analysis, relapse or failure rates at 4 years ranged from 5% for the common iliac artery to 35% for the superficial femoral artery. Polyvascular disease, a poor run-off, multiple stenoses and chronic occlusion were significant risk factors; age and diabetes were not. In the multivariate (stratified Cox regression) analysis, only a location in the superficial femoral artery and a poor preoperative clinical stage were significant risk factors, but type of therapeutic approach was not. The total average cost of treatment was 5,300 Euros, of which 15% was contributed by the patient. Surgery was associated with longer stays (median at 12 days) than endovascular treatments (median 2 days), and was 1.9 times more expensive. In conclusion, the results of the present study suggest that a multidisciplinary approach, orienting the patient to the most appropriate therapeutic pathway, could increase both the quality and the cost-effectiveness of the care.

Sonographic evaluation of the plantar fascia in asymptomatic subjects.

PURPOSE: To evaluate the appearance of the plantar fascia in asymptomatic subjects. MATERIALS AND METHODS: Thirty-one asymptomatic subjects were examined by 2 musculoskeletal radiologists. The plantar fascia was evaluated for thickness, echogenicity, vascularity on power Doppler, rupture, fluid adjacent to the fascia, andcalcifications. RESULTS: The study included 14 men and 17 women (age, 17-79 years; mean, 45 years). The mean thickness of the plantar fascia in men was 3.7 mm (range 2.5-7 mm), and in women 3.5 mm (range, 1.7-5.1 mm). The thickness was greater than 4 mm in 4 men (bilateral in 2). The mean thickness of fascias thicker than 4 mm in men was 5.4 mm (range, 4.3-7 mm). The thickness was greater than 4 mm in 5 women ( bilateral in 4). The mean thickness of fascias thicker than 4 mm in women was 4.7 mm (range, 4.2-5.1 mm). There was no statistically significant difference between men and women and between both heels. Hypoechogenicity was observed in 3 men (bilateral in 2), and in 5 women (bilateral in 6). Hypervascularity, rupture, fluid adjacent to the fascia, and calcifications were not observed. CONCLUSION: A thickness greater than 4 mm and hypoechogenicity, are common in the plantar fascia of asymptomatic subjects. Findings that were not seen in asymptomatic subjects include a thickness greater than 7 mm, hypervascularity on power Doppler, rupture, fluid adjacent to the fascia, and calcifications.

An unusual cause of subtalar pain and instability: accessory calcaneus.

We report on a 45-yr-old male sports instructor with chronic pain and instability of the ankle. He was a recreational basketball player, but because of repeated ankle sprains and chronic subtalar pain this activity became impossible. The radiologic findings were compatible with the diagnosis of accessory calcaneus. In an initial therapeutic approach the patient was treated conservatively with taping and physical therapy, but this failed to relieve the symptoms. Next, a ligamentoplasty was performed. The instability improved, but the pain remained the same. Finally the accessory calcaneus was resected and short term follow-up was unremarkable. Accessory calcaneus is an uncommon anatomical variation that may cause subtalar pain and instability. Resection of the accessory bone may be necessary to provide relief of symptoms. Accessory calcaneus can be well demonstrated on CT, SPECT-CT, and MR. MR and nuclear medicine can indicate instability of the accessory bone by showing bone marrow edema on MR or uptake on fusion imaging.

A bare area of the glenoid misdiagnosed as a cartilage ulceration.

We report on a 17-year-old girl who developed shoulder pain after a fall on an outstretched arm. CT arthrography and MR imaging demonstrated a cartilage defect centrally located in the glenoid. This was accompanied by an eroded appearance of the underlying bone. Since symptoms persisted over several months it was initially thought this represented a cartilage injury. Subsequently arthroscopy was performed and the abnormality was identified as a bare area of the glenoid. A tear of the superior glenohumeral ligament was depicted and was repaired. The bare area is an oval area denuded of cartilage that is probably developmental and that should be differentiated from true cartilage injuries to avoid unnecessary interventions. An eroded appearance of the underlying bone may occur on imaging, a finding that has not been previously reported.

Pigmented villonodular synovitis of the midfoot.

A 60-year-old man presented with a longstanding slowly growing swelling at the dorsal aspect of the left midfoot. The lesion was imaged with CT, ultrasound, and MR. On CT bony erosions were evident. On MR the lesions appeared bifocal and one component was hypointense on T2 weighted images suggesting hemosiderin deposits. The other component was hyperintense on T2 which is more unusual for PVNS. Imaging findings, however, suggested PVNS which was pathologically confirmed. A unique finding in this case is the late age of presentation of the disorder. Also the bifocal nature of the lesion is relatively uncommon.

Tuberculous arthritis of the finger: a forgotten disease.

We present a case of a 64-year-old man from Belgian origin with a chronic painful swelling of the third finger. A chronic arthritis from atypical germ was suspected at the third metacarpo-phalangeal joint on the plain radiography, ultrasonography and MR examination. A few months later, he developed thoracic back pain. Plain radiographs, a Technetium-99m bone scan and MR examination of the thoracic spine revealed a spondylodiscitis of the dorsal spine. A tuberculous origin was found on the biopsy of the affected dorsal vertebral bodies D9 and D10 as suspected on the first imaging examinations of the finger. Besides the patient was found to be HIV-positive. This case shows that it is important to think of musculoskeletal tuberculosis particularly in high-risk persons because if left untreated, it can be devastating.

Practice variability in the management of infrarenal arterial stenoses in seven Belgian hospitals.

This multicentre retrospective study describes the variation of therapeutic options, treatment outcomes and costs for treating infrarenal arterial stenoses as observed in daily practice in 1997-99 in seven Belgian hospitals. Data were obtained from clinical record review and from the sickness fund claims database, and included preoperative functional state, presence of acute ischaemia, diabetes and polyvascular disease, state of the lower-leg run-off arteries, anatomical site and type of lesion, type of treatment, result at 30 days and up to 4 years. A total of 442 episodes were studied, but most analyses dealt with a subgroup of 240 lesions in the common iliac up to the superficial femoral artery. The proportion of surgical treatments (as compared to an endovascular or mixed approach) varied from 15% to 81% between the hospitals. In univariate survival analysis, relapse or failure rates at 4 years ranged from 5% for the common iliac artery to 35% for the superficial femoral artery. Polyvascular disease, a poor run-off, multiple stenoses and chronic occlusion were significant risk factors; age and diabetes were not. In the multivariate (stratified Cox regression) analysis, only a location in the superficial femoral artery and a poor preoperative clinical stage were significant risk factors, but type of therapeutic approach was not. The total average cost of treatment was 5300 Euro, of which 15% was contributed by the patient. Surgery was associated with longer stays (median at 12 days) than endovascular treatments (median 2 d), and was 1.9 times more expensive. In conclusion, the results of the present study suggest that a multidisciplinary approach, orienting the patient to the most appropriate therapeutic pathway could increase both the quality and the cost-effectiveness of the care. In many clinical situations, the endovascular approach appears to offer similar long-term results as surgery, but at a substantially lower cost, both for the patient and for society, especially when performed in a (semi-)ambulatory radiology setting.