Soft tissue tumor imaging in adults: whole-body staging in sarcoma, non-malignant entities requiring special algorithms, pitfalls and special imaging aspects. Guidelines 2024 from the European Society of Musculoskeletal Radiology (ESSR).

OBJECTIVES: The revised European Society of Musculoskeletal Radiology (ESSR) consensus guidelines on soft tissue tumor imaging represent an update of 2015 after technical advancements, further insights into specific entities, and revised World Health Organization (2020) and AJCC (2017) classifications. This second of three papers covers algorithms once histology is confirmed: (1) standardized whole-body staging, (2) special algorithms for non-malignant entities, and (3) multiplicity, genetic tumor syndromes, and pitfalls. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements that had undergone interdisciplinary revision were scored online by the level of agreement (0 to 10) during two iterative rounds, that could result in 'group consensus', 'group agreement', or 'lack of agreement'. RESULTS: The three sections contain 24 statements with comments. Group consensus was reached in 95.8% and group agreement in 4.2%. For whole-body staging, pulmonary MDCT should be performed in all high-grade sarcomas. Whole-body MRI is preferred for staging bone metastasis, with [18F]FDG-PET/CT as an alternative modality in PET-avid tumors. Patients with alveolar soft part sarcoma, clear cell sarcoma, and angiosarcoma should be screened for brain metastases. Special algorithms are recommended for entities such as rhabdomyosarcoma, extraskeletal Ewing sarcoma, myxoid liposarcoma, and neurofibromatosis type 1 associated malignant peripheral nerve sheath tumors. Satisfaction of search should be avoided in potential multiplicity. CONCLUSION: Standardized whole-body staging includes pulmonary MDCT in all high-grade sarcomas; entity-dependent modifications and specific algorithms are recommended for sarcomas and non-malignant soft tissue tumors. CLINICAL RELEVANCE STATEMENT: These updated ESSR soft tissue tumor imaging guidelines aim to provide support in decision-making, helping to avoid common pitfalls, by providing general and entity-specific algorithms, techniques, and reporting recommendations for whole-body staging in sarcoma and non-malignant soft tissue tumors. KEY POINTS: An early, accurate, diagnosis is crucial for the prognosis of patients with soft tissue tumors. These updated guidelines provide best practice expert consensus for standardized imaging algorithms, techniques, and reporting. Standardization can improve the comparability examinations and provide databases for large data analysis.

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where?

OBJECTIVES: Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. RESULTS: Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. CONCLUSION: Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. CLINICAL RELEVANCE: The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. KEY POINTS: • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy.

Ultrasound-guided continuous radiofrequency ablation of the suprascapular nerve for chronic shoulder pain secondary to osteoarthritis: a retrospective cohort study.

OBJECTIVES: The objective of this study is to retrospectively evaluate the use of ultrasound-guided continuous radiofrequency (CRF) lesioning of the suprascapular nerve for treating chronic shoulder pain, due to osteoarthritis. We describe a modified distal and selective ablation technique in the spinoglenoid notch, with motor and sensory stimulation, which protects the motor branch of the nerve from ablation. METHODS: A retrospective analysis was performed of patients, who underwent ultrasound-guided CRF lesioning of the suprascapular nerve from October 2013 to January 2020. During the procedure, the CRF electrode is placed in the spinoglenoid notch, at the distal suprascapular nerve capsular branch. Motor and sensory stimulations are used to confirm the position. CRF lesioning is applied up to three times, at 3 different points, for 1 min each time, at 80° C. RESULTS: In total, 127 first CRF suprascapular nerve lesioning procedures were performed on 101 patients with chronic shoulder pain secondary to osteoarthritis. One hundred nineteen diagnostic ultrasound-guided suprascapular nerve corticosteroid injections were performed prior to ablation. Mean pre-injection Visual Analogue Scale pain score (VAS) was 8.3, with post-injection VAS score of 4.4 at 24 h and 4.5 at 2 weeks. Mean pre-CRF lesioning VAS pain score was 7.7 with post-CRF lesioning VAS score of 4.4 at 24 h and 4.5 at 2 weeks. CONCLUSIONS: Ultrasound-guided CRF lesioning of the suprascapular nerve in the spinoglenoid notch is a safe treatment for chronic osteoarthritic shoulder pain, with repeat treatments infrequently required. It is associated with significant improvement in VAS pain scores. KEY POINTS: • Ultrasound-guided continuous radiofrequency lesioning of the suprascapular nerve in the spinoglenoid notch is a safe treatment for chronic shoulder pain in degenerative disease, with repeat treatments infrequently required. • The procedure is performed under ultrasound guidance, without the use of ionising radiation.

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.

Aneurysmal bone cysts in the spine, causing neurological compromise: safety and clinical efficacy of sclerotherapy utilizing sodium Tetradecyl sulfate foam.

OBJECTIVE: To assess the clinical efficacy, technical feasibility, and safety profile of percutaneous sclerotherapy utilizing sodium tetradecyl-sulfate foam (STS) as a first-line treatment strategy for aggressive spinal aneurysmal bone cysts (sABCs) presenting with neurological compromise. MATERIALS AND METHODS: Between July 2013 and September 2019, eight consecutive patients (5 males; 3 females; mean age 22±17, range 7-52) underwent fluoroscopic/CT-guided intraosseous sclerotherapy for sABCs. Pain and/or neurological compromise was the primary indications. Procedural data, complications, imaging, and clinical results were analyzed. RESULTS: Technical success was achieved in all cases. Mean procedure time was 25±15 min (range 6-167); 1 to 5 repeat treatment cycles (mean 3.7±1.2) utilizing a mean 2.6mls±1.3 (range 1-6) of agitated 3% STS, with a DLP mean dose of 158±91 mGy*cm (range 62-331) per procedure. One reported a minor complication (pain), but no significant complications. Two patients had persistent neurological deficit due to cord compression despite successful sclerotherapy, requiring surgical resection (and were thereby excluded from the final outcome analysis). The remaining six patients demonstrated a significant reduction in tumor volume (p = 0.028), pain (p = 0.027), and SINS (spinal instability neoplastic score) (p = 0.027) at up to 5 years of follow-up (mean 20 ± 16.7, range 7-51 months). CONCLUSION: Percutaneous sclerotherapy with STS is a minimally invasive, technically feasible, safe, and effective first-line treatment for primary sABCs causing pain and neurological compromise, alleviating the need for extensive surgery. It is most effective with three or more treatment cycles, in patients with higher SINS, pain scores, or tumor volumes at the initial presentation.

Musculoskeletal ultrasound imaging standards in the UK: British Society of Skeletal Radiologists (BSSR) position statement.

There has been some concern expressed by UK regulator, the Professional Standards Authority regarding the risks arising from Independent sonographer practices. The Professional Standards Authority presented evidence demonstrating that there are instances of harm occurring because of errors made by non-radiologists performing musculoskeletal ultrasound (MSKUS), particularly MSKUS-guided interventions. This document summarises British Society of Skeletal Radiologists position for Musculoskeletal use of ultrasound in UK, representing the agreed consensus of experts from the British Society of Skeletal Radiologists Ultrasound committee. The purpose of this position statement is to review the current practices affecting the delivery of MSKUS. Recommendations are given for education and training, audit and clinical governance, reporting, and medicolegal issues.

Dual-energy CT in the diagnosis of occult acute scaphoid injury: a direct comparison with MRI.

OBJECTIVES: Scaphoid injuries occult on plain radiography often require further imaging for definitive diagnosis. We investigate the utility of dual-energy computed tomography (DECT) for the detection of acute bone marrow oedema and fracture of scaphoid compared to MRI. MATERIALS AND METHODS: Twenty patients who presented acutely (without prior injury) to the emergency department with clinically suspected occult scaphoid fracture and had MRI of the wrist were prospectively recruited to have DECT (GE Revolution CT). Material decomposition images of the water-calcium base pair were generated and assessed in conjunction with the monochromatic images to permit correlation of marrow signal changes with any cortical disruption for fracture confirmation. The assessment was performed by two musculoskeletal radiologists blinded from MRI results. The statistical difference of MRI and reviewers' detection of acute bone oedema (1 = present, 0 = absent) was performed using the Friedman test (SPSS v.16). RESULTS: MRI showed acute scaphoid fracture and/or bone marrow oedema in 14/20 patients of which 6 also had cortical disruption. On DECT, reviewer A identified oedema in 13 and cortical disruption in 10 patients while reviewer B identified oedema in 10 and cortical disruption in seven of the 14 MRI positive patients. No statistically significant difference in oedema detection on MRI and reviewers of DECT (p value 0.61) but DECT was more sensitive at detecting cortical disruption. CONCLUSION: DECT has the capability to detect acute scaphoid oedema in addition to cortical fractures. However, compared to MRI, DECT has lower contrast resolution and less sensitive in the detection of mild oedema. KEY POINTS: • Dual-energy CT is able to detect acute traumatic scaphoid marrow oedema. • Dual-energy CT has greater detection rate of scaphoid fractures than MRI. • Dual-energy CT is an alternative to MRI for occult scaphoid injury.

Interventional Techniques for Bone and Musculoskeletal Soft Tissue Tumors: Current Practices and Future Directions - Part I. Ablation.

Musculoskeletal (MSK) image-guided oncologic intervention is an established field within radiology. Numerous studies have described its clinical benefits, safety, cost effectiveness, patient satisfaction, and improved quality of life, thereby establishing image-guided oncologic intervention as a preferred pathway in treating patients presenting with specific benign MSK tumors. But there is a paradigm shift on the horizon because these techniques may also support established pillars (surgery, systemic treatment, radiotherapy) in the treatment of malignant MSK tumors. Unlike benign tumors, where they are used as primary therapy lines with curative intent, such interventions can be selected for malignant tumors as adjuvant treatment in painful or unstable bone or soft tissue lesions or as more palliative therapy strategies. Using examples from our clinical practices, we elaborate on the benefits of applying a multidisciplinary approach (traditionally involving MSK radiologists, oncologists, orthopaedic surgeons, microbiologists, pathologists, physiotherapists, and pain management experts), ideally within a sarcoma treatment center to deliver a patient-specific therapy plan and illustrate methods to assess the benefits of this model of care.In this article, we review the current repertoire of ablation techniques, demonstrate why such procedures offer value-based alternatives to conventional treatments of specific tumors, and reflect on future directions. Additionally, we review the advantages and limitations of each technique and offer guidance to improve outcomes.

Interventional Techniques for Bone and Musculoskeletal Soft Tissue Tumors: Current Practices and Future Directions - Part II. Stabilization.

Percutaneous image-guided oncologic interventions have rapidly evolved over the last two decades as an independent strategy or used within a first-, second-, or even third-line strategy in the treatment of musculoskeletal (MSK) tumors. Abundant mostly nonrandomized publications have described the safety, efficacy, and reproducibility of implementing percutaneous therapies both with curative and palliative intent. In this article, we continue to share our experience in bone and MSK soft tissue interventions focusing on stabilization and combined ablation and stabilization. We propose a pathway and explore future directions of image-guided interventional oncology related to skeletal disease. We reflect on the advantages and limitations of each technique and offer guidance and pearls to improve outcomes. Representing patterns from our practices, we demonstrate the role of collaborative working within a multidisciplinary team, ideally within a dedicated tumor treatment center, to deliver patient-specific therapy plans that are value based and favored by patients when given the choice.

Metastatic Primary Gastric Squamous Cell Carcinoma: An Uncommon Presentation of a Rare Malignancy.

Primary gastric squamous cell carcinoma is a very rare disease. A 53-year-old male with history of hypertension, alcoholism, and nicotine abuse presented to the hospital after a syncopal episode. He complained of bloating abdominal pain, early satiety, and poor appetite. A CT of his abdomen and pelvis revealed a gastric mass with diffuse hepatic metastasis. A gastric mass was seen on upper endoscopy and biopsies revealed gastric squamous cell carcinoma. There was no involvement of the esophagus. This case should add to the limited literature and serve as a reminder that while this is a rare malignancy, it must be considered when evaluating a gastric mass.

Diffuse Large B-Cell Lymphoma Mimicking an Ulcerative Colitis Flare.

We present a case of non-Hodgkin lymphoma of the rectum in a 41-year-old African American male with a 1 year history of ulcerative colitis and no previous immunomodulatory therapy. The patient presented with a 10-day history of hematochezia, for which endoscopy was performed with gross findings indicative of ulcerative colitis flare. Tissue biopsy, however, demonstrated significant lymphoid infiltrating regions with histologic findings suggestive of a diffuse large B-cell lymphoma. Non-Hodgkin's lymphoma accounts for less than 1% of all cases of colorectal cancer. Associated risk factors have been previously reported but, were absent in the patient's history. This suggests the possibility of distinct genetic abnormalities inherent to the tumor and/or an underlying germline mutation inherent to the patient that may have contributed to the premature development of diffuse large B-cell lymphoma.

Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial.

OBJECTIVE: To compare arthroscopic hip surgery with physiotherapy and activity modification for improving patient reported outcome measures in patients with symptomatic femoroacetabular impingement (FAI). DESIGN: Two group parallel, assessor blinded, pragmatic randomised controlled trial. SETTING: Secondary and tertiary care centres across seven NHS England sites. PARTICIPANTS: 222 participants aged 18 to 60 years with symptomatic FAI confirmed clinically and with imaging (radiography or magnetic resonance imaging) were randomised (1:1) to receive arthroscopic hip surgery (n=112) or a programme of physiotherapy and activity modification (n=110). Exclusion criteria included previous surgery, completion of a physiotherapy programme targeting FAI within the preceding 12 months, established osteoarthritis (Kellgren-Lawrence grade ≥2), and hip dysplasia (centre-edge angle <20 degrees). INTERVENTIONS: Participants in the physiotherapy group received a goal based programme tailored to individual patient needs, with emphasis on improving core stability and movement control. A maximum of eight physiotherapy sessions were delivered over five months. Participants in the arthroscopic surgery group received surgery to excise the bone that impinged during hip movements, followed by routine postoperative care. MAIN OUTCOME MEASURES: The primary outcome measure was the hip outcome score activities of daily living subscale (HOS ADL) at eight months post-randomisation, with a minimum clinically important difference between groups of 9 points. Secondary outcome measures included additional patient reported outcome measures and clinical assessment. RESULTS: At eight months post-randomisation, data were available for 100 patients in the arthroscopic hip surgery group (89%) and 88 patients in the physiotherapy programme group (80%). Mean HOS ADL was 78.4 (95% confidence interval 74.4 to 82.3) for patients randomised to arthroscopic hip surgery and 69.2 (65.2 to 73.3) for patients randomised to the physiotherapy programme. After adjusting for baseline HOS ADL, age, sex, and study site, the mean HOS ADL was 10.0 points higher (6.4 to 13.6) in the arthroscopic hip surgery group compared with the physiotherapy programme group (P<0.001)). No serious adverse events were reported in either group. CONCLUSIONS: Patients with symptomatic FAI referred to secondary or tertiary care achieve superior outcomes with arthroscopic hip surgery than with physiotherapy and activity modification. TRIAL REGISTRATION: ClinicalTrials.gov NCT01893034.

Acute Pancreatitis Secondary to Hemobilia after Percutaneous Liver Biopsy: A Rare Complication of a Common Procedure, Presenting in an Atypical Fashion.

Percutaneous Liver Biopsy is an often-required procedure for the evaluation of multiple liver diseases. The complications are rare but well reported. Here we present a case of a 60-year-old overweight female who underwent liver biopsy for elevated alkaline phosphatase. She developed acute pancreatitis secondary to hemobilia, with atypical signs and symptoms, following the biopsy. She never had the classic triad of RUQ pain, jaundice, and upper GI hemorrhage. There were also multiple negative imaging studies, thus complicating the presentation. She was successfully treated with ERCP, sphincterotomy, balloon sweep, and stent placement. Angiography and transcatheter embolization were not required.

The iliotibial band in acute knee trauma: patterns of injury on MR imaging.

OBJECTIVE: To delineate the spectrum of knee injuries associated with sprains and tears of the distal iliotibial band (ITB). MATERIALS AND METHODS: A retrospective review of 200 random MRI scans undertaken for acute knee trauma was performed. Scans were excluded if there was a history of injury over 4 weeks from the time of the scan, septic arthritis, inflammatory arthropathy, previous knee surgery, or significant artefact. In each scan, the ITB was scored as normal, minor sprain (grade 1), severe sprain (grade 2), and torn (grade 3). The menisci, ligaments, and tendons of each knee were also assessed. RESULTS: The mean age was 27.4 years (range, 9-69 years) and 71.5% (n = 143) of the patients were male. The ITB was injured in 115 cases (57.5%). The next most common soft tissue structure injured was the anterior cruciate ligament (ACL) in 53.5% of cases (n = 107). Grade 1 ITB injury was seen in 90 of these 115 cases (45%), grade 2 injury in 20 cases, and grade 3 injury in only five cases. There is a significant association between ITB injury and ACL rupture (p < 0.05), as well as acute patellar dislocation (p < 0.05). There were ten cases of significant posterolateral corner injury, and all were associated with ITB injury, including four ITB tears. Only two cases of isolated ITB injury were seen (1%). CONCLUSIONS: ITB injury is common in acute knee trauma and is associated with significant internal derangement of the knee, especially cruciate ligament rupture, posterolateral corner injury, and patellar dislocation.

Multiple hereditary exostoses and ischiofemoral impingement: a case-control study.

OBJECTIVE: To assess whether there is a significant difference in the ischiofemoral space in patients with multiple hereditary exostoses affecting the proximal femora compared to normal patients. INTRODUCTION: Ischiofemoral impingement is an increasingly recognized cause of hip and buttock pain. This causes narrowing of the ischiofemoral space resulting in an abnormal quadratus femoris muscle. MATERIALS AND METHODS: We performed a retrospective search for individuals with MHE with proximal femoral involvement on pelvic MRI over a 7-year period (2006-2013). Suitable patients were age- and sex-matched with a control group. The minimum ischiofemoral space (MIFS) was recorded in each hip, as was the presence of edema and atrophy of quadratus femoris and concomitant hip osteoarthrosis. MRI features suggestive of ischiofemoral impingement were defined as MIFS less than 10 mm or an abnormal quadratus femoris muscle. RESULTS: Twenty-one hips in 11 individuals with MHE were included in the study. A total of 42 hips were analyzed. The mean age was 37 years (range, 13-72 years) and 55% were male. There was a significant difference (p < 0.05) in the MIHS in individuals with MHE (mean, 10.7 mm, range, 0-21 mm) compared to a control group (mean, 18.1 mm, range, 10.5-26.5 mm). MRI features suggestive of ischiofemoral impingement were seen in 13/21 (62%) hips in the MHE group and 0/21 (0%) in the control group. CONCLUSIONS: The reduced ischiofemoral space and associated quadratus femoris abnormalities in patients with MHE involving the proximal femora may account for hip/buttock symptoms in the absence of significant degenerative change.

Internal derangement of the knee in fibular hemimelia: radiographic and MRI findings.

BACKGROUND: Fibular hemimelia is a rare bone dysplasia with partial or complete absence of the fibula. There are many associated lower limb deformities. METHODS: We describe the commonly associated bone and soft tissue abnormalities in the knee joint in a case series of six knees in five patients with fibular hemimelia who underwent both radiographic and MR imaging. RESULTS: In all knees, there was an elongated conjoint tendon of the lateral collateral ligament and biceps femoris. In five out of six knees, there was trochlear dysplasia. In four out of six, there was complete absence of the anterior cruciate ligament. In four out of six, there was an abnormal lateral meniscus (three were hypoplastic and one absent). CONCLUSION: These associations in fibular hemimelia, although unpredictable, have relevance in the guidance of further orthopaedic management in this complex condition.

The association of infrapatellar fat pad oedema with patellar maltracking: a case-control study.

OBJECTIVE: To look for any association between oedema in the superolateral portion of the infrapatellar fat pad and patellar maltracking. MATERIALS AND METHODS: We compared two groups of knee MRI with regard to five patellar maltracking parameters. The first group included 100 knees with evidence of oedema in the superolateral aspect of the infrapatellar fat pad (the study group). The second group included another 100 knee MRI that had a normal infrapatellar fat pad (the control group). The five patellar maltracking parameters assessed were the trochlear depth, tibial tuberosity-trochlear groove distance (TTTG), patellar translation, patellofemoral angle (PFA) and the Insall-Salvati index. RESULTS: There was a statistically significant difference in the Insall-Salvati index, patellar translation and PFA between the two groups (p value of <0.001, <0.001 and 0.004 respectively, Student's t test). There was a higher prevalence of patella alta, lateral patellar displacement (LPD) and lateral patellar tilt in the study group (p value of <0.001, <0.001 and 0.011 respectively, Fisher's exact test). Sixty out of 100 knees in the study group had at least one abnormal patellar maltracking parameter in comparison to 16 out of 100 knees in the control group (p < 0.001, Fisher's exact test). CONCLUSION: Oedema in the superolateral portion of Hoffa's fat pad, the MRI feature of fat pad impingement, is associated with patellar maltracking.

Ultrasound detection of heel enthesitis: a comparison with magnetic resonance imaging.

OBJECTIVE: Seronegative arthropathies are associated with inflammatory enthesopathy. The involvement of Achilles tendon and plantar aponeurosis is common, with strong tendency toward fibrosis and calcification. This study tests the diagnostic efficacy of ultrasound (US) in depicting enthesitis, and compares sonographic images with magnetic resonance images (MRI). METHODS: We studied 32 patients with a diagnosis of seronegative arthropathies, 22 men, 10 women, mean age 29 years. They had heel enthesopathy without typical conventional radiographic evidence. T1 and T2 weighted and short-tau inversion recovery (STIR) MRI sequences were obtained in axial and sagittal planes. An HDI 3000 ATL US device equipped with 12 MHz linear transducer was used to examine the enthesis. Three independent observers assessed the reliability of sonographic images by using video recording of the US examinations. RESULTS: US images of enthesitis showed loss of normal fibrillar echotexture of tendon (100%), lacking the homogeneous pattern, with blurring of tendon margins (56.2%) and irregular fusiform thickening (84.3%). The affected tendons showed intratendinous lesions with ill defined focal tendon defects filled with a mixture of fluid, fat, and/or granulation tissue, with loss of their tightly packed echogenic dots. MRI showed tendon enlargement (62.5%) with loss of the normal flattened hypointense appearance, focal thickening and rounded configuration at the insertion site (31.2%), intermediate T1 and high T2 signals, and diminished signals within the pre-Achilles fat pad due to inflammatory edema. Among all patients, 40.6% developed osteitis. CONCLUSION: MRI was not sensitive compared to US in detecting early changes of enthesopathy. Fatty degeneration appeared late in MRI, while it was detected earlier using US. MRI was not able to detect any calcification process at the insertion site, while US images clearly showed the very early signs of the calcification process. We recommend use of US for early diagnosis and in treatment and followup of patients with tendon enthesopathy, to accurately identify and diagnose different pathologic and biomechanical changes.