Milwaukee shoulder syndrome. Fifteen additional cases and a description of contributing factors.

Fifteen additional patients with Milwaukee shoulder syndrome are described, bringing our total series to 30 cases. The condition occurred predominantly in elderly women and was characterized by severe glenohumeral joint degeneration and dissolution of the fibrous rotator cuff. Synovial fluids contained few leukocytes, but were often blood tinged. Basic calcium phosphate crystal aggregates and particulate collagens were noted in nearly all fluids, and collagenase activity was detectable in some, but not all, fluids. The knee joints were involved with a similar process in about half of our patients. In contrast to primary osteoarthritis, lateral tibiofemoral compartment involvement was common. Factors that may predispose to this syndrome included deposition of calcium pyrophosphate dihydrate crystals, direct trauma or chronic joint overuse, chronic renal failure, and denervation.

Listeroisis in immunosuppressed patients. A cluster of eight cases.

Bactermia due to listeria monocytogenes developed in eight patients who were receiving immunosuppresive medications during a 15 month period at one hospital. Seven survived. Meningitis was documented in only the four who received kidney transplants. Their neurologic signs were minimal, indicating a need to treat any immunosuppressed patient with Listeria bacteremia for meningitis. During this period the incidence of Listeria bactermia in immunosuppressed patients greatly exceeded that previously observed in this hospital or reported elsewhere, but the incidence of infection with other opportunistic agents was not increased. As with previously decreased listeria outbreaks in nonimmunosuppressed patients, no source or mechanism of spread could be identified. Thus, disease due to L. monocytogenes may occur focally among immunosuppressed populations, a pattern which also appears to be emerging for other opportunistic agents. A patient's exposure to different opportunistic agents may be as important as the kind of immunosuppressive therapy he recieves in determining which opportunistic infection he will acquire or even whether any infection will occur.

Detection of femoral head avascular necrosis in adults by SPECT.

Twenty-one adult patients with the clinical diagnosis of avascular necrosis (AVN) of the femoral head were examined with radionuclide angiography, planar bone scintigraphy, and single photon emission computed tomography (SPECT). A final diagnosis of AVN was established for 15 symptomatic patients with a total of 20 involved hips. SPECT and planar bone scintigraphy were considered positive for AVN only if a photopenic bony defect could be identified. Using SPECT bone scintigraphy, 12 of 15 symptomatic patients and 17 of 20 involved hips (sensitivity of 0.85) were correctly identified, whereas with planar imaging only eight of 15 patients and 11 of 20 involved hips were detected. There were no false-positive diagnoses on SPECT or planar bone scintigraphy. In addition, hyperemia in the region of the proximal femoral metaphysis was demonstrated in six of 20 involved hips. It is concluded that by identifying a photopenic defect that is not evident on planar views, SPECT can contribute to the diagnosis of AVN of the femoral head. In addition, metaphyseal hyperemia appears to be a promising new scintigraphic sign of AVN worthy of further investigation.

Comparison of high-resolution MRI and SPECT bone scintigraphy for noninvasive imaging of the temporomandibular joint.

Prospective evaluation by magnetic resonance imaging (MRI) and both single photon emission computed tomography (SPECT) and planar bone scintigraphy was undertaken in 31 temporomandibular joints (TMJs) of 21 symptomatic patients. When compared with the results of subsequent arthrography, MRI (0.88) was more sensitive than SPECT (0.76) or planar (0.56) scintigraphy for detection of internal derangement of the TMJ. A diagnostic sensitivity of 0.96 was achieved when the results of either MRI or SPECT was considered evidence of internal joint derangement. Five symptomatic TMJs, clinically thought to be abnormal, were positive on SPECT but showed no evidence of anterior disk displacement at the time of arthrography. In such instances, SPECT may be detecting functionally significant altered joint mechanics that are not evident on anatomic imaging of the TMJ.

Animal model for studying the chronic effects of herniated disks and spinal surgery.

A successful model to study both herniated intervertebral disks and spinal operations such as laminectomy has not been described. Two procedures were developed in nonhuman primates: One produces an elevated nerve root simulating a herniated disk; the second is a laminectomy that simulates the operation in humans. Twenty-five surgical procedures were performed with no complications. A myelographic abnormality typical of a disk herniation results from the simulated disk herniation. The chronic effects of herniated disk and spinal surgery can be studied with this model.

Chronic capitolunate instability.

Twelve patients, twelve to thirty-two years old, were evaluated for complaints of chronic vague pain, weakness, and clicking in the wrist that had followed a significant but remote dorsiflexion injury to the wrist. Although a standard orthopaedic examination and plain roentgenograms of the carpus were unremarkable, a dorsal-displacement stress test done under fluoroscopic control with the radius fixed showed dorsal subluxation of the capitate out of the cup of the lunate, accompanied by a marked feeling of apprehension by the patient. This was also associated with a painful snap or click due to a sudden dorsal attitude and ulnar shift of the lunate, best elicited with the wrist in slight ulnar deviation. We believe that this condition is due to attenuation of the radiocapitate ligament resulting from prior trauma. Eleven patients were operated on. The volar radiocapitate ligament was tightened by tethering its central portion to the radiotriquetral ligament, partially obliterating the space of Poirier. Slight extension of the wrist was lost by this procedure, but the capitate could no longer be passively displaced and the lunate became stable. Using both objective and subjective criteria, six patients had an excellent result; three, good; one, fair; and one, poor. There was an average final loss of 15 degrees of extension and 19 degrees of flexion of the wrist. The average length of follow-up was four years and four months (range, twenty-four to 109 months). We concluded that insufficiency of the radiocapitate ligament after trauma to the wrist is one cause of chronic symptomatic capitolunate instability. Shortening of the radiocapitate ligament is recommended to stabilize the lunate and capitate.

Excessive retroversion of the glenoid cavity. A cause of non-traumatic posterior instability of the shoulder.

Seventeen shoulders in ten adolescents were evaluated for non-traumatic posterior instability. Each patient had significant disability in throwing a ball, swimming, arm-blocking in football, and bench-pressing weights. Each patient had excessive retroversion of the glenoid. Five shoulders had a posterior opening-wedge osteotomy of the scapular neck to correct the excessive retroversion of the glenoid cavity. Acromial bone was used as graft material in the first four shoulders. Three shoulders lost some correction but only one required revision, which was done using cortical iliac bone as a graft and screw fixation. This technique was used primarily in the fifth shoulder. Excessive retroversion of the glenoid cavity is a developmental deformity and is considered the primary etiology of posterior instability of the shoulder. The posterior opening-wedge osteotomy of the scapular neck corrects the defect and the instability.

MR imaging of the abnormal sternoclavicular joint--a pictorial essay.

The sternoclavicular (SC) joint can be affected by a wide variety of pathologic conditions. Imaging is usually needed for diagnosis and staging. Although the use of magnetic resonance (MR) imaging has become indispensable in the evaluation of most joints, MR has received little attention in SC joint evaluation. Recently, however, it has been shown that detailed MR images of the normal SC joint can be obtained. This pictorial essay explores the differential diagnosis of the abnormal SC joint and helps to determine the role of MR imaging in the SC joint imaging algorithm.

Scintigraphic skeletal "doughnut" sign due to giant cell tumor of the fibula.

Although the "doughnut" sign in brain scintigraphy is a well known phenomenon, similar findings have recently been reported in bone scintigraphy in osseous and nonosseous lesions. A skeletal doughnut sign in bone scintigraphy caused by giant cell tumor of the proximal fibula is presented with a brief review of literature.

High-resolution bone scintigraphy of the adult wrist.

Bony anatomic landmarks of the wrist (e.g., pisiform, hook of hamate, radioulnar joint, and styloid processes of the radius and ulna) were routinely identified in 28 adult patients examined for wrist pain. With the wrists prone and immobilized, bone scintigrams were obtained for 500,000 counts with an asymmetric (133 to 161 keV) Tc-99m energy window and either a converging (best choice) or straight-bore, high-resolution collimator. High-resolution scintigraphy precisely localized degenerative joint disease (nine patients), scaphoid fractures (five), pisiform fracture (one), lunate avascular necrosis (one), radioulnar arthritis (one), septic or inflammatory arthritis (six), ulnocarpal impingement (two), and reflex sympathetic dystrophy syndrome (two). Images obtained palm down with the wrist in ulnar deviation helped identify increased uptake within the scaphoid. Fracture and significant bone or joint disease were excluded in one patient.

Increased sacroiliac joint uptake after lumbar fusion and/or laminectomy.

Of 753 adult patients undergoing SPECT and planar bone scintigraphy for the evaluation of low back pain, 43 (6%) showed either unilateral or bilateral increased sacroiliac joint (SIJ) uptake. Five of the 58 abnormal joints were only identified with SPECT (9%), whereas 20 of the 58 abnormal joints were much more convincingly demonstrated by SPECT (34%). Fifteen of the 43 patients with increased SIJ uptake had undergone prior lumbar laminectomy and/or spinal fusion. Such spinal surgery can increase impact loading on the SIJ, leading to mechanical overload and sacroiliitis. Degenerative joint disease, trauma, or other benign pathology accounted for the remaining patients with increased SIJ uptake. The authors conclude that for patients with a history of lumbar spinal fusion and/or laminectomy, increased SIJ uptake usually is caused by altered spinal mechanics rather than malignancy or infection.

Detection of osteomyelitis in the neuropathic foot: nuclear medicine, MRI and conventional radiography.

The diagnostic efficacy of (1) combined three-phase bone scintigraphy and In-111 labeled WBC scintigraphy (Bone/WBC), (2) MRI, and (3) conventional radiography in detecting osteomyelitis of the neuropathic foot was compared. Conventional radiography was comparable to MRI for detection of osteomyelitis. MRI best depicted the presence of osteomyelitis in the forefoot. Particularly in the setting of Charcot joints, Bone/WBC was more specific than conventional radiography or MRI.

Hindfoot coronal alignment: a modified radiographic method.

Accurate clinical evaluation of the alignment of the calcaneus relative to the tibia in the coronal plane is essential in the evaluation and treatment of hindfoot pathologic condition. Previously described radiographic views of the foot and ankle do not demonstrate the true coronal alignment of the calcaneus relative to the tibia. Some of these views impose on the patient an unnatural posture that itself changes hindfoot alignment, whereas other methods distort the coronal alignment by the angle of the x-ray beam. Our purpose was to develop a modified radiographic view and measurement method for determining an angular measurement of hindfoot coronal alignment based on a cadaver study of the radiographic characteristics of the calcaneus and motion analysis of standing subjects. The view was obtained by having the subject stand on a piece of cardboard to create a foot template. The template was then positioned so that each foot was x-rayed perpendicular to the cassette while still maintaining the natural base of support. A method using multiple ellipses was developed to determine more accurately the coronal axis of the posterior calcaneus. A study using cadavers was performed in which radio-opaque markers were placed on multiple bony landmarks on the calcaneus. The tibia was held fixed in a vertical position, and the foot was x-rayed using the above techniques in different degrees of rotation without changing the relation of the calcaneus to the tibia. The radiographs of the modified Cobey and our view were examined to verify which markers were visible at different angles of rotation and how the hindfoot alignment measurements changed with foot rotation. To define further the differences between the views, an analysis of postural stability was conducted while the subjects were standing with the feet in the positions for imaging both the Buck modification of the Cobey view and our hindfoot alignment view. The combined results of the cadaver, radiographic measurement, and postural stability segments of the study reveal that this coronal hindfoot alignment view and measurement method is reproducible, more closely measures "true" coronal hindfoot alignment, and is more clinically applicable because the alignment is measured while the patient is standing with a normal angle and base of stance. The modified radiographic measurement method relies on posterior calcaneal anatomic landmarks, is less affected by rotation of the foot and ankle, and is reproducible between observers.

Lumbar facet joint injection in low back pain and sciatica: preliminary results.

Fluoroscopically controlled intra-articular facet joint block is a reliable method of diagnosing low back pain and sciatica caused by lumbar facet arthropathy. Of 20 patients studied, 13 had complete and immediate relief of pain, confirming the diagnosis, Six patients have been free of pain for more than six months following a single facet joint block with injection of a local anesthetic and corticosteroid suspension. Preliminary findings suggest that computed tomography has an important role in diagnosing symptomatic facet arthropathy.

Lumbar facet joint injection in low back pain and sciatica: description of technique.

Lumbar facet arthropathy is an important cause of low back pain and sciatica. Intra-articular facet block can confirm symptomatic facet joint disease. Good understanding of the anatomy of the joint and fluoroscopic control are essential for intra-articular placement of anesthetics and steroids.

The double fat fluid level: lipohemarthrosis of the knee associated with suprapatellar plica synovialis.

Lipohemarthrosis is a frequent occurrence following intrarticular fracture. The contour of the fat and blood interface in the knee joint is dependent upon suprapatellar anatomy. Anatomic variations of the suprapatellar joint space can significantly alter the radiographic appearance of lipohemarthrosis. Three cases are presented in which a double fat-fluid level was identified, due to presence of a well developed suprapatellar plica synovialis. Recognition of the variable appearance of lipohemarthrosis of the knee is important to avoid overlooking this finding in the traumatized patient.