Talar metastasis of mucinous lung adenocarcinoma with fluid-fluid levels: a rare presentation mimicking a benign tumor.

The differential diagnosis of bone tumors in the talus is broad and includes both benign and malignant conditions. Metastases, although very rare, are one of these conditions. The typical nonspecific clinical and radiological presentations of metastases are a diagnostic challenge, and a high level of suspicion is needed in order to perform an adequate diagnostic approach. Moreover, they can present with features which have classically been associated with benign conditions such as fluid-fluid levels. We present a rare case of talar metastasis of a mucinous pulmonary adenocarcinoma that presented with fluid-fluid levels and was initially misdiagnosed as a giant-cell tumor with areas of secondary aneurysmal bone cyst transformation.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

OBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle.

OBJECTIVES: Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval. RESULTS: A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement. CONCLUSION: According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton's neuroma, particularly using platelet-rich plasma and corticosteroids, respectively. KEY POINTS: • The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle. • Strong consensus was obtained for all statements. • The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton's neuroma and PRP for plantar fasciitis.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part V, knee.

OBJECTIVES: Interventional procedures around the knee are widely adopted for treating different musculoskeletal conditions. A panel of experts from the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the existing literature to assess the evidence on image-guided musculoskeletal interventional procedures around the knee, with the goal of highlighting some controversies associated with these procedures, specifically the role of imaging guidance, as well as the efficacy of the medications routinely injected. METHODS: We report the results of a Delphi-based consensus of 53 experts in musculoskeletal radiology, who reviewed the published literature for evidence on image-guided interventional procedures around the knee to derive a list of pertinent clinical indications. RESULTS: A list of 10 statements about clinical indications of image-guided procedures around the knee was created by a Delphi-based consensus. Only two of them had the highest level of evidence; all of them received 100% consensus. CONCLUSIONS: Ultrasonography guidance is strongly recommended for intra-articular and patellar tendinopathy procedures to ensure the precision and efficacy of these treatments. Prospective randomized studies remain warranted to better understand the role of imaging guidance and assess some of the medications used for interventional procedures around the knee. KEY POINTS: • A list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the knee was produced by an expert panel of the ESSR. • Strong consensus with 100% agreement was obtained for all statements. • Two statements reached the highest level of evidence, allowing us to strongly recommend the use of ultrasonography to guide intra-articular and patellar tendon procedures to ensure higher accuracy and efficacy of these treatments.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part IV, hip.

OBJECTIVES: Image-guided musculoskeletal interventional procedures around the hip are widely used in daily clinical practice. The need for clarity concerning the actual added value of imaging guidance and types of medications to be offered led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb in order to derive a list of clinical indications. METHODS: In this article, we report the results of a Delphi-based consensus of 53 experts who reviewed the published literature for evidence on image-guided interventional procedures offered in the joint and soft tissues around the hip in order of their clinical indications. RESULTS: Ten statements concerning image-guided treatment procedures around the hip have been collected by the panel of ESSR experts. CONCLUSIONS: This work highlighted that there is still low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are essential to better confirm the benefits and objectively clarify the role of imaging to guide musculoskeletal interventional procedures around the hip. KEY POINTS: • Expert consensus produced a list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the hip. • The highest level of evidence was only reached for one statement. • Strong consensus was obtained for all statements.

Value of multidetector computed tomography for the differentiation of delayed aseptic and septic complications after total hip arthroplasty.

OBJECTIVE: The differentiation between delayed aseptic and septic complications of total hip arthroplasty is crucial to allow appropriate surgical planning and timely antimicrobial treatment. The aim of this study was to investigate the utility of multidetector computed tomography (CT) findings to diagnose aseptic mechanical loosening, granulomatous reaction, and periprosthetic joint infection in patients who underwent total hip arthroplasty before revision surgery. MATERIALS AND METHODS: Ninety-six consecutive patients with a clinical suspicion of periprosthetic complications underwent revision surgery over an 8-year period. All patients had been evaluated preoperatively using multidetector CT without contrast media. Two blinded musculoskeletal radiologists reviewed multidetector CT images, including periprosthetic soft-tissue accumulation, prosthetic acetabular malposition, periprosthetic osteolysis, enlarged iliac lymph nodes, and heterotopic ossification. Risk factors for aseptic and septic loosening were identified using multivariate analysis. RESULTS: Multidetector CT-related variables independently associated with periprosthetic joint infection were high periprosthetic soft-tissue accumulation, periprosthetic osteolysis without expansile periosteal reaction and enlarged iliac lymph nodes. On the other hand, the absence of the following radiological signs: low or high periprosthetic soft-tissue accumulation, mild or severe periprosthetic osteolysis, and enlarged iliac lymph nodes, were predictors of aseptic mechanical loosening. Low periprosthetic soft-tissue accumulation, severe periprosthetic osteolysis with expansile periosteal reaction, and mild acetabular malposition were significant variables associated with granulomatosis. CONCLUSION: Multidetector CT findings are useful to differentiate between aseptic and septic complications before revision surgery. The presence of osteolysis with expansile periosteal reaction appeared to be a time-dependent variable.

Diffusion-weighted magnetic resonance imaging is useful for assessing inflammatory myopathies.

INTRODUCTION: Short tau inversion recovery (STIR) sequences in whole-body MRI are usually used for detecting muscle edema (ME) in inflammatory myopathies. We evaluated b-value 800 diffusion-weighted imaging (b800 DWI). METHODS: Two radiologists independently and a consensus reader retrospectively reexamined 60 patients with inflammatory myopathies and 15 controls. For each participant, 78 muscles were analyzed with 3 sets of imaging acquisitions: T1-weighted (T1) turbo spin echo and STIR; T1 and DWI; and T1, STIR and DWI. Mean edema per patient was compared between sequences. Agreement was evaluated. RESULTS: Diffusion-weighted imaging detected more ME compared with STIR (P < 0.001). Agreement between readers was better with both sequences (k = 0.94) than with b800 DWI (k = 0.89) or STIR (k = 0.84) alone. DISCUSSION: Diffusion-weighted imaging is a valuable add-on for the study of inflammatory myopathies. Muscle Nerve 59:555-555, 2019.

Correlation between quantitative and semiquantitative magnetic resonance imaging and histopathology findings in dermatomyositis.

OBJECTIVES: The aim of this study was to compare muscle biopsy findings, as well as clinical and analytical features, with those of magnetic resonance imaging (MRI) studies of muscle in patients with dermatomyositis. METHODS: All patients from the Longitudinal Myopathy Cohort of the Hospital Clínic de Barcelona were prospectively included in the study from 2009 to 2016. MRI images of muscle and fascial oedema were compared with muscle pathology results using both quantitative and semi-quantitative scores. RESULTS: We found a statistically significant association between the inflammatory infiltrate and both muscle (r2=0.54, p=0.001) and fascial oedema (r2=0.54, p<0.001). In addition, muscle oedema was significantly associated with punched-out vacuoles (p=0.04) and muscle enzymes in serum (r2=0.34, p=<0.01 for CK and r2=0.22, p<0.05 for aldolase). The number of treatment drugs received at the time of MRI was inversely associated with the number of muscle inflammatory cells in the biopsy and with both muscle and fascial oedema (all p<0.05). CONCLUSIONS: Key MRI findings correlate with the main features of dermatomyositis muscle biopsy results, suggesting that MRI findings could be used as a surrogate marker of disease activity.

Update on Whole-body MRI in Musculoskeletal Applications.

Whole-body magnetic resonance imaging (WB-MRI) is a powerful tool increasingly used to assess oncologic and nononcologic diseases. WB-MRI provides information about diffuse multifocal pathologies with excellent anatomical definition through high soft tissue contrast and spatial resolution as well as valuable functional information from diffusion-weighted images. In addition to its roles in establishing the diagnosis and assessing the extent and severity of disease, WB-MRI is also useful for monitoring the response to treatment for malignant and benign systemic diseases affecting the musculoskeletal system. This article reviews and updates the applications of WB-MRI in current practice, discussing the role of this helpful tool in various conditions involving the musculoskeletal system including bone metastases, hematologic cancers, inflammatory processes, infections, and multisystemic-multifocal bone, nerve, vascular, and muscle/soft tissue disorders, as well as other idiopathic conditions.

Whole-body MRI and pathological findings in adult patients with myopathies.

Magnetic resonance imaging (MRI) is considered the most sensitive and specific imaging technique for the detection of muscle diseases related to myopathies. Since 2008, the use of whole-body MRI (WBMRI) to evaluate myopathies has improved due to technical advances such as rolling table platform and parallel imaging, which enable rapid assessment of the entire musculoskeletal system with high-quality images. WBMRI protocols should include T1-weighted and short-tau inversion recovery (STIR), which provide the basic pulse sequences for studying myopathies, in order to detect fatty infiltration/muscle atrophy and muscle edema, respectively. High signal intensity in T1-weighted images shows chronic disease with fatty infiltration, whereas high signal intensity in STIR indicates an acute stage with muscle edema. Additional sequences such as diffusion-weighted imaging (DWI) can be readily incorporated into routine WBMRI study protocols. Contrast-enhanced sequences have not been done. This article reviews WBMRI as an imaging method to evaluate different myopathies (idiopathic inflammatory, dystrophic, non-dystrophic, metabolic, and channelopathies). WBMRI provides a comprehensive estimate of the total burden with a single study, seeking specific distribution patterns, including clinically silent involvement of muscle areas. Furthermore, WBMRI may help to select the "target muscle area" for biopsy during patient follow-up. It may be also be used to detect related and non-related pathological conditions, such as tumors.

Accuracy of Computed Tomography-Guided Joint Aspiration and Computed Tomography Findings for Prediction of Infected Hip Prosthesis.

BACKGROUND: Infection after total hip arthroplasty remains a diagnostic challenge. We assessed the accuracy of computed tomography (CT)-guided joint aspiration combined with CT findings for prediction of septic hip prosthesis before revision surgery. METHODS: A total of 96 patients (64.6% men; mean age, 68 years) scheduled for elective revision surgery due to suspicion of infection after total hip arthroplasty underwent CT-guided joint aspiration. Volume and microbiological cultures of aspirated fluid and salient findings on CT scans, including periprosthetic soft-tissue mass, malpositioning of the prosthesis, periprosthetic osteolysis, reactive enlarged lymph nodes, and heterotopic ossification, were assessed by a blinded radiologist. RESULTS: Septic hip prosthesis was shown on revision surgery in 35 patients (36.4%), with Staphylococcus epidermidis isolated in 54.3% of cases. Culture of the aspirated fluid yielded the same microorganism in 24 patients (68.6%). The accuracy of preoperative CT-guided joint aspiration was 86.5%. High volume (>1 mL) of aspirated fluid was recorded in 32 patients (33.3%). In the multivariate analysis, high volume on CT aspiration, accumulation of soft tissue exceeding the joint margin, osteolysis without bone insufflation, and enlarged iliac lymph nodes were significant predictors of infected hip prosthesis. Similar results were obtained after adjustment of the model by the presence of aggressive granulomatosis. CONCLUSION: Preoperative CT-guided joint aspiration is accurate to diagnose septic hip prosthesis based on CT imaging findings and volume and bacterial culture of the aspirated fluid. Enlarged iliac lymph nodes emerged as a strong predictor of infection.

Hypertrophy of the tensor fascia lata muscle as a complication of total hip arthroplasty.

INTRODUCTION: Hypertrophy of the tensor fascia lata muscle (HTFLM) is a rare complication after total hip arthroplasty (THA) and is a potential source of pain, palpable mass, or both. MATERIALS AND METHODS: We retrospectively analyzed 1285 primary THAs and 482 THA revisions (THAR) performed at our center from 2008 to 2014. Among these, five patients had HTFLM (average age 68.8 years). The type of surgery and symptoms were evaluated, as were imaging studies (CT or MRI) of both hips (10 hips), and functional outcomes with the Merle d'Aubigné score. RESULTS: The suspected diagnosis was established at an average of 30.2 months after surgery. Four cases occurred after THA and one case after THAR. A modified Hardinge approach was used in four cases and a Röttinger approach in one case. Two cases had pain and palpable mass in the trochanteric region and three cases only pain. The asymmetric HTFLM of the THA side against the nonsurgical side was confirmed by measuring the cross section of the tensor fascia lata muscle on imaging. The sartorius muscle was measured for reference in each case. The Merle d'Aubigne scale had a mean value of 16.6 (range 13-18) at 38 months after the procedure. CONCLUSIONS: HTFLM after THA is a benign condition that could be mistaken for a tumor when presenting as a palpable mass. We propose that it should be considered in the differential diagnosis of pain in the lateral aspect of hips that have previously undergone THA.

Prospective comparison of whole-body (18)F-FDG PET/CT and MRI of the spine in the diagnosis of haematogenous spondylodiscitis.

PURPOSE: To prospectively compare (18)F-FDG PET/CT and MRI in the diagnosis of haematogenous spondylodiscitis METHODS: The study included 26 patients (12 women, 14 men; mean age 59 ± 17 years) with clinical symptoms of infection of the spine. Patients who had had prior spinal surgery or any type of antibiotic therapy in the previous 3 months were excluded from the study. Whole-body PET/CT 60 min after injection of 4.07 MBq/kg of (18)F-FDG and an MRI scan of the spine was performed in all patients. SUVmax in an area surrounding the lesions with the suspicion of infection as well as a background SUVmean in a preserved area of the spine were calculated for quantification. Infection was diagnosed by microbiological documentation in cultures of image-guided spinal puncture fluid or blood. Infection was excluded if symptoms were absent without antimicrobial therapy during a follow-up of at least 6 months. RESULTS: Spondylodiscitis was confirmed in 18 of the 26 patients. Staphylococcus aureus was found in 8 patients, Mycobacterium tuberculosis in 4, Escherichia coli in 2 and other pathogens in 4. Of the remaining 8 patients, the diagnoses were degenerative spondyloarthropathy in 5 and vertebral fracture in 3. The sensitivity, specificity, and positive and negative predictive value were 83%, 88%, 94% and 70% for (18)F-FDG PET/CT, and 94%, 38%, 77% and 75% for MRI, respectively. The accuracies of (18)F-FDG PET/CT and MRI were similar (84% and 81%, respectively). The combination of (18)F-FDG PET/CT and MRI detected the infection in 100% of the patients with spondylodiscitis. (18)F-FDG uptake, quantified in terms of SUVmax corrected by the background SUVmean, was significantly higher in patients with spondylodiscitis than in those without infection (p < 0.001). CONCLUSION: Due to its high specificity, (18)F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. Quantification of uptake in terms of SUVmax was able to discriminate infection of the spine from other processes in this series of patients.

MR-arthrography assessment after repair of chronic meniscal tears.

PURPOSE: The aims of this study were to assess the healing rate of repair of chronically torn meniscal tear with MR-arthrography and to evaluate the relationship between the clinical and the radiographic outcomes and the impact of the meniscal section on healing. METHODS: MR-arthrography was performed at a median of 10.5 months (range 6-55) after surgery in 28 patients and healing assessed using Henning's criteria. All lesions were chronic (>3 months). Repairs were carried out at a median 14 months (range 6-80) from initial diagnosis. Eleven patients (39%) had ACL ligament reconstruction as well. All lesions were located in the red or red-white zone. Patients were followed for a median of 18.5 months (range 8-68). Functional outcomes were evaluated using Barrett's healing criteria, Lysholm and Tegner score pre- and postoperatively. RESULTS: Clinical healing of the lesion according to Barrett's criteria was achieved in 24 patients (85.7%). Both Lysholm and Tegner scores improved significantly after the surgery (p < 0.05). According to Henning's criteria, 15 of the menisci healed completely (53.5%), 10 partially (35.7%) and 3 failed (10.8%). There was no significant difference between the healing process in the posterior horn and the body of the meniscus (n.s.). No correlation was found between the healing results and the clinical scores. ACL reconstruction did not influence the healing process (n.s.). Patients waiting more than 1 year from lesion to surgery seem to have a higher rate of failure (p = 0.02). CONCLUSIONS: The results found suggest good short-term clinical and anatomic outcomes post-repair of meniscal lesions, despite their chronic nature. Longer waiting times may have negative effects on the healing process. Partial healing occurred often, but the meniscus was painless and stable. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Costal Chondroid Tumors Mimicking Intraabdominal Masses: The Pivotal Role of Computed Tomography in Diagnosis.

Teaching Point: Costal chondroid tumors can mimic abdominal masses and, when located in the right hypochondrium, may suggest hepatic origin. Computed tomography is essential to determine their origin and nature and to guide appropriate treatment.

Radiological evaluation of acetabular erosion after antibiotic-impregnated polymethylmethacrylate spacer (Spacer-G).

Different types of hip spacers have been described (hand-made, custom-molded or prefabricated) for treatment of a chronic hip infection. A potential disadvantage of monoblock prefabricated spacer is that it may cause acetabular bone loss. This study assesses the radiological acetabular erosion using an antibiotic-impregnated pre-fabricated polymethylmethacrylate Spacer-G. We retrospectively reviewed the radiographs of thirty five patients who were managed with Spacer-G to treat chronic hip infection. No acetabular erosion were observed in thirty two patients with a mean time from the first to second stage and from the first to the last radiograph of 5.09 and 3.77 months respectively. In three patients the time between the radiographs was more than one year and the second stage was not performed; two developed a protrusion acetabuli whereas the other one a destruction of the acetabular roof. Using a Spacer-G in chronic hip infection treatment for less than one year is not associated with radiological acetabular erosion if the patient is maintained at partial weight bearing.

Pseudo Green Hair.

Green hair is due to insoluble copper deposits in the hair of blonde people. Although it is most frequently due to an increase in the copper content of algaecides in swimming pools, other causes have been recognized. Herewith, we present a case of a blonde girl who had previously commercially highlighted her hair and the hair had turned green following a swim in a pool with excess copper content in the water. Lifeguard swimming pool commented another previously affected blonde female swimmer 2 days ago. To date, <10 cases involving swimming pools with clearly increased copper concentrations have been published, and to the best of our knowledge, no similar case without traces of copper in X-ray microanalysis has been reported in the literature.

Postoperative Hip MR Imaging.

Postoperative imaging of the hip used to be dominated by radiographs, computed tomography, and occasionally nuclear medicine studies, given that most surgeries were arthroplasties or, less commonly, core decompressions. The indications and procedures performed have expanded well beyond arthroplasties and now include labral procedures (resections, repairs, and reconstructions), osteochondroplasties, acetabuloplasties, and removal of loose bodies, among others. As a result, postoperative evaluation of the hip now often includes MR imaging and MR arthrography. This article discusses normal postoperative appearances and some of the more common complications associated with hip arthroscopy and hip arthroplasty with a focus on MR imaging.

MRI findings prior to return to play as predictors of reinjury in professional athletes: a novel decision-making tool.

BACKGROUND: Because MRI has shown great accuracy in assessing acute muscle injuries, identification of risk factors for reinjury before return to play (RTP) in professional athletes during the healing process could be very relevant. We assessed the value of MRI findings prior to RTP as predictors of reinjury. METHODS: Retrospective observational study of 59 professional athletes, mean age 26 years, with first-time acute muscle injury and successful rehabilitation ready to RTP. They underwent MRI within 6 days of the injury and within 7 days prior to RTP. The primary outcome was reinjury. Risk of reinjury was assessed using radiological signs in control MRI scans before RTP. The risk was classified as low, medium or high when none, one or two radiological signs were observed, respectively. RESULTS: Reinjury occurred in 9 participants, with a rate of 15.2%. None of the baseline MRI-related variables was significantly associated with reinjury. In the control MRI scan performed within 7 days prior to RTP, three independent findings were significantly associated with reinjury. These included transversal and/or mixed connective tissue gap (p = 0.002), intermuscular oedema (p = 0.015) and callus gap (p = 0.046). In the predictive model of the risk of reinjury, the presence of two of these radiological signs, together with interstitial feathery oedema, was associated with a high risk of recurrence (OR 29.58, 95% CI 3.86-226.64; p = 0.001). CONCLUSIONS: In professional athletes with acute muscle injuries of the lower limbs successfully rehabilitated, some radiological signs on MRI performed shortly before RTP were associated with a high risk of reinjury.