MRI and arthroscopy correlations of the elbow: a case-based approach.

The number of elbow arthroscopies and indications for the procedure have increased significantly since the advent of modern elbow arthroscopy in the 1980s. In addition to the patient history, physical examination, and plain radiography, MRI is an important tool for the clinician in diagnosing several pathologies within and around the elbow. Understanding the pathophysiology and clinical presentation and being familiar with the MRI characteristics of a variety of elbow conditions will assist the physician in making an accurate diagnosis and help guide appropriate treatment.

MRI and arthroscopy correlations of the hip: a case-based approach.

Disorders of the hip joint can be physically disabling for the patient and a diagnostic challenge for the physician. Advances in imaging the hip with MRI can help the physician determine a more specific diagnosis for patients with acute or chronic hip pain. MRI and particularly magnetic resonance arthrography have helped raised awareness of nonarthritic hip problems and have made the diagnosis of hip problems much easier. Intra-articular and extra-articular processes can be evaluated with MRI; multiple sequences are available to increase the sensitivity and specificity for detecting specific pathology around the hip. Because the hip is a deep joint within a large soft-tissue envelope, MRI more precisely delineates the sources of hip pain by evaluating the soft tissues and ligamentous structures around the hip. It is helpful to understand the role of MRI in evaluating common pathologic conditions within the hip joint, including labral tears, chondral lesions, loose bodies, tears of the ligamentum teres, femoral acetabular impingement, developmental dysplasia of the hip, and pigmented villonodular synovitis. Hip arthroscopy, a less invasive technique for treating hip problems, has also contributed to the rapid growth of interest in this area of orthopaedic surgery. Hip arthroscopy can be used to evaluate disorders in the intra-articular region (central and peripheral compartments) and periarticular region (iliopsoas bursa and tendon disorders) as well as those in the peritrochanteric region.

[Secondary synovial chondromatosis of the ankle joint]. / Sekundäre synoviale Chondromatose des oberen Sprunggelenks.

Synovial chondromatosis of the ankle is a rare condition, particularly secondary chondromatosis. In view of a possible traumatic pathogenesis, chondromatosis should be kept in mind in daily trauma and orthopedics practice. Diagnostic imaging gives a first indication. The key to differentiating between the primary and secondary forms is histological identification. This case shows the necessity of exact differentiation, even in cases of a causal link with a specific injury.

[Calcaneus fractures]. / Kalkaneusfrakturen.

Fractures of the calcaneus generally occur in the setting of high-energy trauma, resulting in complex, three-dimensionally oriented fracture patterns. Surgical treatment is typically indicated for displaced intra-articular fractures, permitting restoration of calcaneal height, width and overall morphology, in addition to the posterior facet articular surface where possible, and enabling late in situ arthrodesis as a means of salvage in the event of post-traumatic arthritis. The present article briefly discusses our preferred methods for the management of calcaneal fractures. An English full text version of this article is available at SpringerLink as supplemental.

Diagnostic importance of MRI and CT scans for synovial osteochondromatosis of the temporomandibular joint.

Since synovial chondromatosis (SC) clinically mimics symptoms of internal derangements of the TMJ, the diagnostic value of MRI and CT, overlooked for years, is discussed in the presented case. Multiple amorphous calcifications in the left infratemporal fossa and upper synovial compartment of the TMJ were detected on the CT and MRI scans. The patient underwent open TMJ arthrotomy and removal of 15 calcified loose bodies. SC may be diagnosed radiographically when sclerosis of the glenoid fossa, soft tissue edema, and intraarticular radio-opaque loose bodies are detected. Advanced imaging of the TMJ, such as MRIs and CTs, are indispensible methods to obtain differential diagnoses for long-standing suspicious pathologies of the temporomandibular joint.

Is MRI adequate to detect lesions in patients with ankle instability?

BACKGROUND: Chondral lesions, peroneal tendon tears, and other disorders in patients with chronic ankle instability may not be detected by preoperative MRI. Also, MRI often is obtained and interpreted at the referring institution, leading to variability in reading. QUESTIONS/PURPOSES: We assessed the accuracy of the radiologists' and orthopaedic surgeon's reading of preoperative MRI for diagnosing ankle lesions in patients with ankle instability warranting surgery. PATIENTS AND METHODS: We retrospectively reviewed 133 patients who underwent 135 surgeries for lateral ankle ligament reconstruction with concomitant ankle arthroscopy and who had preoperative MRI. RESULTS: We found 72 associated lesions in 66 of the 135 surgeries, including 38 chondral injuries, 18 peroneus brevis tears, seven loose bodies, and nine other miscellaneous abnormalities. Eliminating eight lesions for which the decision to operate was not based on operative findings, there were 127 surgeries with 64 associated lesions that required intraoperative confirmation or were detected intraoperatively. In the original reports, the radiologists identified 39% (15) of the chondral injuries, 56% (10) of the peroneal tears, and 57% (four) of the loose bodies. Radiologists' MRI sensitivity for detecting lesions was 45%. The attending surgeon identified 47% (18) of the chondral injuries, 89% (16) of the loose bodies, 71% (five) of the peroneus brevis tears, and the posterior talus process lesion, with a sensitivity of 63%. CONCLUSIONS: Our data suggest orthopaedic surgeons should review preoperative MRIs and also suggest the sensitivity of MRI may not be adequate to detect lesions in these patients before surgery. LEVEL OF EVIDENCE: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Cartilage lesions in anterior bony impingement of the ankle.

PURPOSE: The aim of this study was to investigate the correlations between spur severity, clinical characteristics, and articular cartilage lesions in patients with anterior bony impingement. METHODS: The study included 57 ankles in 57 patients (48 male and 9 female patients; age range, 15 to 59 years) who had undergone a spur resection for anterior impingement. We excluded spurs in patients with osteoarthritis with joint space narrowing. Spur severity was classified by use of the McDermott scale. The correlations between spur severity, clinical characteristics, and articular cartilage lesions were evaluated. Differences in the mean lengths of the tibial spurs were examined according to the presence or absence of tram-track lesions, spur fragmentation, and loose bodies. RESULTS: The duration of pain, degree of sports activity, and presence of mechanical instability showed no relation to spur severity. Of the ankles, 28 (49.1%) were grade 1, 1 (1.8%) was grade 2, and 28 (49.1%) were grade 3. Cartilage lesions were present in 46 ankles (80.7%). Spur severity was correlated with the degree of cartilage lesions (Spearman rho = 0.30, P = .02). Grade 3 ankles had more spur fragmentation than grade 1 or 2 ankles. The mean length of the tibial spurs with tram-track lesions or spur fragmentation was longer than that without these lesions. CONCLUSIONS: The results suggest that cartilage lesions are present even in ankles with small spurs and that the degree of cartilage lesions increases as spurs become larger. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Factors affecting recovery after arthroscopic labral debridement of the hip.

PURPOSE: The purpose of this study was to develop and validate a model predicting whether patients would have shorter-than-typical or longer-than-typical recoveries after hip arthroscopy for labral tears. METHODS: We retrospectively reviewed 268 cases of hip arthroscopy implemented between 2000 and 2007 by 2 orthopaedic surgeons at our institution. The development cohort consisted of patients with magnetic resonance angiography-identified labral tears and a history and physical examination consistent with either labral pathology or loose bodies. Univariate analysis targeted preoperative patient characteristics correlated with the risk of longer-than-typical recoveries. Multivariate logistic regression was applied to generate an algorithm predicting risk of longer-than-typical recovery based on baseline characteristics. The algorithm was tested in the validation sample of 52 patients who were treated in 2007 and was found to be valid. RESULTS: Five predictors for longer-than-typical recovery were identified: Workers' Compensation status, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear. The multivariate algorithm was developed and successfully validated. CONCLUSIONS: This study identifies many new predictors of recovery, and it also corroborates those that have already been identified. The 5 predictors for longer-than-typical recovery identified by our validated multivariate algorithm were Workers' Compensation status, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The outcome of hip arthroscopy in Australian football league players: a review of 27 hips.

PURPOSE: The purpose of this study was to investigate on hip pathology found at hip arthroscopy in Australian Football League (AFL) players and describe our current treatments and outcomes. METHODS: From 2003 to 2008, 24 consecutive AFL players (27 hips) had arthroscopic hip surgery by use of the lateral position. Patients were assessed preoperatively and postoperatively with the modified Harris Hip Score (MHHS) and Nonarthritic Hip Score (NAHS) and postoperatively with a satisfaction survey. RESULTS: All hips were available for review. The mean duration of follow up was 22 months (range, 6 to 60 months). The mean age was 22 years (range, 16 to 29 years). The mean body mass index was 24 points (range, 21 to 26 points). The mean traction time was 21 minutes (range, 11 to 60 minutes). The most common pathology was a rim lesion, affecting 93% of cases. Microfracture was performed in 22%. Synovitis was found in 70%, and this was most commonly associated with a rim lesion. Labral pathology was present in 33%, the most common of which was labral separation. On the femoral side, 81% had cam impingement and underwent a femoral neck ostectomy. Rim lesions and labral pathology were the most commonly associated lesions. Also seen were loose os acetabuli in 7% and loose bodies in 7%. The former were associated with labral tears and required repair. The MHHS and NAHS improved in all patients postoperatively, and they maintained their improvement from 1 year up to 4 years. In all but 1 case, the players returned to playing at the AFL level and were satisfied with their outcome. CONCLUSIONS: Using hip arthroscopy, we have observed high satisfaction levels and return to preinjury levels of play in all but 1 case. Postoperative hip scores (MHHS and NAHS) have improved significantly, and this improvement has been maintained for up to 4 years. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Fixation of detached osteochondritis dissecans lesions with bioabsorbable pins: clinical and histologic evaluation.

PURPOSE: The purpose was to evaluate the effect of fixation of detached free fragments of osteochondritis dissecans (OCD) (International Cartilage Repair Society OCD IV) on not only the clinical outcome, including functional and radiographic assessment, but also postoperative second-look arthroscopic and histologic evaluation. METHODS: Nine International Cartilage Repair Society OCD IV fragments were fixed with bioabsorbable pins made of poly-L-lactic acid after curettage of the bed and bone grafting. In 4 cases with severe cartilage damage in the fragments, after resection of the damaged part, trimmed fragments were fixed and osteochondral autologous transplantation was performed to cover the remaining defects. The follow-up period was at least 2 years (range, 2 to 3 years). Lysholm score and computed tomography (CT)/magnetic resonance imaging (MRI), second-look arthroscopy, and biopsy findings were examined postoperatively. RESULTS: All patients ultimately could return to previous sports activity, and the mean postoperative Lysholm score was 97 (range, 90 to 100). At 6 months, CT/MRI scans showed complete union and smooth continuity of articular surface in all cases. Second-look arthroscopy in 7 cases showed that fixed fragments were stable and that there were no progressive degenerative changes in the cartilage. Postoperative histologic examination in 4 cases showed almost normal cartilage from surface to bottom in terms of viability and quality. In addition, new bone trabeculae were covering dead bone trabeculae, which is called creeping substitution. CONCLUSIONS: Our study shows good short-term clinical results, as well as confirmation of healing on CT/MRI and second-look arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Primary synovial osteochondromatosis of the first metatarsophalangeal joint, literature review of a rare presentation and a case report.

Synovial osteochondromatosis is a rare condition, found mainly in larger joints, where as it is particularly rarer in small joints especially the metatarsophalangeal joint. We report the case of a 45-year-old man with primary synovial osteochondromatosis in the first metatarsophalangeal joint. Following surgical intervention, the diagnosis was confirmed with histological examination. The patient had successful management and is completely symptom free on 12-month review. A summary of the case and review of the current literature with the incidence of this condition and risks involved are discussed.

Technique and indications of elbow arthroscopy. A twelve-cases report.

AIM: Describe the technique of the elbow arthroscopy and discuss their indications through a series of 12 cases and a review of the literature. METHODS: We report a retrospective study of a short series of 12 cases of elbow arthroscopy performed on 4 years. The indications of this technique were loose bodies in 7 cases, parcellar displaced fracture of radial head in 3 cases, fracture of coronoid process in one case and osseous impingement in one case. RESULTS: We have noted no complications and at a mean follow up of 18 months (6 to 40 months) our results were almost satisfactory. CONCLUSION: Elbow arthroscopy is an effective but delicate technique. Its indications are not frequent. They are dominated by loose bodies.

Elbow arthroscopy.

Arthroscopy of the elbow was originally considered to be an unsafe procedure because of the small size of the elbow joint capsule and its proximity to several crucial neurovascular structures. Over the past decade, however, the procedure has become safer and more effective. These improvements can be attributed to a better understanding of elbow anatomy and of the disorders about the elbow as well as to advances in arthroscopic equipment and surgical technique. The most common indications for elbow arthroscopy include removal of loose bodies, synovectomy, débridement and/or excision of osteophytes, capsular release, and the assessment and treatment of osteochondritis dissecans. More recent advances have expanded the indications of elbow arthroscopy to include fracture management (eg, radial head fractures) and the treatment of lateral epicondylitis.

Analysis of magnetic resonance imaging characteristics and pain in temporomandibular joints with and without degenerative changes of the condyle.

The aim of this study was to investigate temporomandibular joint (TMJ) pain and magnetic resonance imaging characteristics in 104 TMJs with and 58 without degenerative changes of the condyle, such as osteophytes, erosion, avascular necrosis, subcondral cyst and intra-articular loose bodies. TMJ images were also assessed for flattening, retropositioning and hypomobility of condyle and disc displacement. Comparison of the TMJ side-related data showed a significant relationship between disc displacement without reduction (DDwoR) and the presence of degenerative bony changes (p=0.00). Flattening, retropositioning and hypomobility of condyle showed no significant difference in relation to the presence or absence of degenerative bony changes. Retropositioning of the condyle was significantly associated to disc displacement with reduction (DDwR) (p=0.00), while condylar hypomobility was significantly more frequent in TMJ with DDwoR (p<0.05). Independent of the presence or type of DD, TMJ pain was more frequent in the presence of degenerative bony changes. When considering only DDwR, TMJ pain was significantly associated to a degenerative condition (p=0.03). When there were no degenerative bony changes, TMJ pain was significantly more frequent in DDwoR (p=0.04). Despite the present findings, the absence of symptoms in some patients with condylar bony changes suggests that the diagnosis of osteoarthritis should be established by evaluation of magnetic resonance images in association with clinical examination.

Synovial chondromatosis of the temporomandibular joint with middle cranial fossa extension.

Synovial chondromatosis of the temporomandibular joint (TMJ) is relatively rare. An unusual case with extension through the glenoid fossa and into the middle cranial fossa is reported. Invasion of the infratemporal fossa and the middle cranial fossa was seen on both computed tomography and magnetic resonance imaging. Complete removal of the loose bodies with excision of the affected synovium is the accepted treatment of synovial chondromatosis. A conservative approach should be followed while trying to eliminate any remaining lesion in the infratemporal fossa and the middle cranial fossa. An overview of previously reported cases of synovial chondromatosis with cranial extensions is also presented.

Localized pigmented villonodular synovitis presenting as a loose body following minor trauma in the knee: a case report.

Localized pigmented villonodular synovitis (LPVS) is widely accepted to frequently develop symptoms resembling internal derangement in the knee, including limitation of motion and episodes of giving way and locking. We report the case of a 31-year-old man with LPVS displaying an unusual presentation. After sustaining a twisting injury to the knee, he suffered constant but subtle knee discomfort, sudden attacks of pain and a feeling of a loose body. Arthroscopic examination 1 month after injury revealed a freely mobile tumor in the supra-patellar pouch that was not pedunculated and displayed no soft tissue attachments to the synovium. Histological findings for the tumor were consistent with a diagnosis of LPVS. This case illustrates that LPVS may present with symptoms of a loose body after trauma to the knee.

A large intra-articular loose body in the metacarpophalangeal joint of the middle finger mimicking a calcified tumorous lesion: a case report.

We will report on a case with a large intra-articular loose body in the metacarpophalangeal (MP) joint of the middle finger in a 30-year-old-male, which was mimicking a calcified tumourous lesion adjacent to the palmar side of the metacarpal head. It was easily removed through the palmar approach.

[Osteochondritis dissecans]. / Osteokondritis dissekans.

Osteochondritis dissecans (OCD) is a disease of unknown etiology, characterized by separation of necrotic bone from its bony bed. While the juvenile form seen in patients with open physes has a 60-90% rate of spontaneous resolution, the adult form has virtually no chance of spontaneous healing. Plain X-rays are sufficient for the diagnosis, and magnetic resonance imaging (MRI) is essential for evaluation of disease progression and/or healing. The clinical correlation of MRI criteria defined in recent years to determine stability of the lesion is high. Juvenile OCD can be treated conservatively if there are no signs of instability on magnetic resonance images. Adult patients or unstable lesions in children should be treated surgically. For stable lesions, arthroscopic antegrade perforation is indicated to increase vascularity and stimulate healing. Unstable or displaced lesions should be treated with debridement, internal fixation, and cancellous bone grafting. Although cannulated metal screws are the most widely used implants for internal fixation, biodegradable implants have also been utilized in recent years. Loose fragments that are too deformed to be internally fixed should be removed and cartilage reconstruction techniques should be employed for the remaining crater. Long-term results of loose body removal alone are unsatisfactory. Modern cartilage restoration techniques are technically demanding due to the large, deep, and unconfined nature of the defect in the femoral condyle.

Comparison of magnetic resonance arthrography with arthroscopy for imaging of shoulder injuries: retrospective study.

BACKGROUND Arthroscopy is the established 'gold standard' diagnostic investigation for detection of shoulder disorders. We aimed to compare the diagnostic accuracy of arthroscopy with magnetic resonance arthrography (MRA) for detection of shoulder disorders. METHODS Patients who underwent arthroscopy by a single surgeon and preoperative MRA between February 2011 and March 2012 for shoulder instability were identified. MRAs were reported by experienced musculoskeletal radiologists. Labral tears, anterior labral tears, superior labral anterior posterior (SLAP) lesions, posterior labral tears, rotator-cuff tears (RCTs), osteoarthritis, loose bodies and Hill-Sachs lesions were identified. Sensitivity, specificity, positive predictive value and negative predictive value, positive likelihood ratio and negative likelihood ratio were calculated. RESULTS A total of 194 patients were identified. The sensitivity and specificity for anterior labral tears was 0.60 and 0.92, SLAP lesions was 0.75 and 0.81, posterior labral tears was 0.57 and 0.96, any labral tear was 0.87 and 0.76, Hill-Sachs lesions was 0.91 and 0.91, RCTs was 0.71 and 0.86, osteoarthritis was 0.72 and 0.95, and loose bodies was 0.22 and 0.96, respectively. The positive predictive value and negative predictive value for anterior labral tears were 0.88 and 0.71, SLAP lesions was 0.64 and 0.88, posterior labral tears was 0.74 and 0.45, any labral tear was 0.89 and 0.71, Hill-Sachs lesions was 0.66 and 0.98, RCTs was 0.47 and 0.95, osteoarthritis was 0.70 and 0.95, and loose bodies was 0.27 and 0.95, respectively. CONCLUSIONS MRA has high diagnostic accuracy for labral tears and Hill-Sachs lesions, but whether MRA should be the first-line imaging modality is controversial.