Imaging features of gluteal in vitro fertilization injection granulomas, with delayed clinical presentation simulating soft tissue sarcoma.

OBJECTIVES: To review the clinical and imaging findings of patients with remote history of intramuscular (IM) in vitro fertilization (IVF) gluteal injections, presenting with signs and symptoms of a possible gluteal soft tissue sarcoma. METHODS AND METHODS: Retrospective review of consecutive patients with a history of prior IVF therapy referred for MRI evaluation of a gluteal soft tissue mass was performed. Six patients were reviewed, with 5 patients meeting study inclusion criteria. Imaging exams (ultrasound n = 3, MRI n = 5) were assessed for lesion location, morphology, and intrinsic imaging characteristics. One case proceeded to percutaneous biopsy with histopathologic correlation. RESULTS: Average patient age was 43 years (range 38-50). Mean time interval between IVF IM injections and MRI was 5.7 years (range 2.2-13 years). Clinical findings included palpable gluteal mass (5/5) and local pain (4/5). Ultrasound showed heterogeneous subcutaneous lesions with varying complex cystic/solid internal echogenicity. On MRI, each case illustrated an irregularly marginated lesion, mean maximal dimension 3.5 cm (range 1.5-5.9 cm), within the deep gluteal subcutaneous fat composed of solitary (1/5) or multifocal (4/5) lobules demonstrating internal areas of high T1 and homogeneous low T2 fat suppressed signal with surrounding peripheral reticular high T2 signal. Correlative histological assessment showed central areas with features of fat necrosis and a peripheral inflammatory rim. CONCLUSIONS: In the setting of prior IVF therapy, imaging features of an irregularly marginated, deep subcutaneous gluteal lesion with inflammatory soft tissue changes surrounding solitary or multifocal areas of loculated fat signal may be seen as an inflammatory response to previous inadvertent subcutaneous injection(s).

Prevalence and risk factors of low bone mineral density in psoriatic arthritis: A systematic review.

OBJECTIVE: Prevalence and impact of low bone mineral density (BMD) in psoriatic arthritis (PsA) is not well understood. We aimed to synthesize current evidence regarding the prevalence, impact, and risk factors for low BMD and fractures in PsA. METHODS: A systematic literature search limited to human studies was conducted without language restriction. Data on BMD, prevalence of osteoporosis, osteopenia and fractures, risk factors, morbidity, and mortality due to low BMD in PsA patients were collected. RESULT: A total of 21 studies (16 case-control, 4 cross-sectional, and 1 prospective cohort) were reviewed after screening 639 titles and abstracts. In all, 17 studies compared PsA patients with one or more control group (four normal controls, five psoriasis, and eight other rheumatic diseases with or without healthy controls). The number of PsA patients in the studies ranged from 8 to 2212 with a mean (standard deviation) age of 35 (10) to 63.4 (6.2), and mean PsA duration of 2.25-13.65 years. Reported prevalence of osteoporosis varied from 1.4% to 68.8%. Low BMD was identified as a significant problem in 13 of the 21 studies. Age, female sex, postmenopausal status, PsA duration, presence of erosions, and cumulative steroid dose were associated with lower BMD. Fractures (12-40%) were associated with postmenopausal status and axial disease. No studies reported on hospitalization and mortality due to low BMD. CONCLUSION: This systematic review synthesizes current evidence on BMD and its impact in PsA. High likelihood of bias and inconsistent results suggest a need for well-designed longitudinal studies on bone health in PsA.

Trunnionosis: the latest culprit in adverse reactions to metal debris following hip arthroplasty.

The imaging findings of periprosthetic soft tissue lesions (pseudotumours) have been typically defined in the context of newer second-generation metal-on-metal hip arthroplasty. More recently, similar findings have been described in the setting of non-metal-on-metal prostheses. Although uncommon, wear and corrosion between the metal surfaces at the head-neck ('trunnionosis') and neck-stem interfaces are the potential culprits. With modular junctions containing at least one cobalt chromium component frequently present in hip arthroplasty prostheses, the incidence of this mode of adverse wear may be higher than previously thought (irrespective of the specific bearing couple used). In the present report, we described a case of a severe adverse local tissue reaction secondary to suspected corrosion at the head-neck taper in a metal-on-polyethylene total hip arthroplasty and reviewed the literature. Knowledge of this topical entity should help radiologists facilitate early diagnosis and ensure early management of this potentially serious complication.

Is the MAdrid Sonographic Enthesitis Index useful for differentiating psoriatic arthritis from psoriasis alone and healthy controls?

OBJECTIVE: To assess the usefulness of the MAdrid Sonographic Enthesitis Index (MASEI) in classifying patients as having psoriatic arthritis (PsA) and comparing entheseal abnormalities between patients with PsA, psoriasis alone (PsC), and healthy controls (HC). METHODS: Patients with PsC were assessed to exclude inflammatory arthritis. The MASEI scoring system was used to quantify the extent of ultrasonographic (US) entheseal abnormalities. The total MASEI score was categorized into items that reflected inflammatory abnormalities (MASEI-inflammatory) and chronic damage (MASEI-damage). Nonparametric tests were used to compare MASEI scores across the groups. A cutoff point of MASEI ≥ 20 was used to calculate the sensitivity and specificity of the MASEI to classify patients as having PsA. RESULTS: Patients with PsA (n = 50), PsC (n = 66), and HC (n = 60) were assessed. Total MASEI scores were higher in patients with PsA than in those with PsC, and both those groups were higher than HC (p < 0.0001). MASEI-inflammatory showed a similar trend (p < 0.0001). MASEI-damage was higher in patients with PsA compared to both patients with PsC and HC (p < 0.0001); however, no difference was observed between patients with PsC and HC. No significant difference in MASEI scores was found across the 3 groups in patients with a body mass index > 30. The sensitivity of the MASEI score to correctly classify patients as having PsA was 30% and the specificity was 95% when compared to HC and 89% when compared to PsC. CONCLUSION: The severity of US entheseal abnormalities is highest in patients with PsA followed by PsC and is lowest in healthy controls. MASEI can specifically classify patients as having PsA.

Massive localised lymphoedema: clinical presentation and MR imaging characteristics.

Three morbidly obese women were referred to us with suspected soft-tissue sarcomas. All lesions arose from the medial subcutaneous tissues of the thigh, and were shown to represent massive localised lymphoedema (MLL), a rare condition occurring in morbidly obese adults. MR imaging typically demonstrates a sharply demarcated, pedunculated mass consisting of fat partitioned by fibrous septae surrounded by a thickened dermis. There is oedema both within the mass and tracking along the subcutaneous septae in a "lace-like" fashion outwards from the pedicle, outlining large lobules of fat. Minimal enhancement is observed within the dermis of the lesion following intravenous gadolinium administration. Obesity is a growing problem that is likely to result in an increase in the prevalence of this condition; therefore, familiarity with the radiological appearance is important in establishing a correct diagnosis in this condition that may mimic a soft-tissue sarcoma.

Low-dose infliximab (3 mg/kg) significantly reduces spinal inflammation on magnetic resonance imaging in patients with ankylosing spondylitis: a randomized placebo-controlled study.

OBJECTIVE: To evaluate the influence of low-dose infliximab (IFX) on spinal inflammation scored by magnetic resonance imaging (MRI). The dose recommended for rheumatoid arthritis (3 mg/kg) is also clinically effective for ankylosing spondylitis (AS), although effects on spinal inflammation as defined by MRI have yet to be described in a placebo-controlled trial. METHODS: In a 12-week double-blind period, patients were randomized 1:1 to receive either IFX 3 mg/kg at 0, 2, and 6 weeks, or placebo. Spinal inflammation in discovertebral units (DVU) was measured by the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI Index at baseline and 12 weeks by 3 readers blinded to timepoint and treatment allocation. We also compared reliability and discrimination of the SPARCC MRI index based on evaluation of the entire spine (23 DVU score) compared to assessment of only the 6 most severely affected DVU (6 DVU score). RESULTS: At Week 12, patients treated with IFX experienced mean reductions of 55.1% and 57.2% in the 6 DVU and 23 DVU SPARCC scores, respectively, compared with a mean increase of 5.8% and decrease of 3.4% in 6 DVU and 23 DVU scores, respectively, for patients taking placebo (p < 0.001). A large treatment effect (Guyatt's effect size >or= 1.7) and high reliability was evident and comparable between 6 DVU and 23 DVU scoring methods. CONCLUSION: Treatment with low-dose IFX leads to a large treatment effect on spinal inflammation as measured by MRI. Scoring for inflammation of only the most severely affected regions of the spine by MRI is comparable to assessment of the entire spine.

Magnetic resonance imaging features of osseous manifestations of early acquired syphilis.

We report the case of a 64-year-old man who initially presented with a maculopapular rash followed several weeks later by bilateral shin pain and infiltrative cutaneous lesions over the lower legs. The plain radiographs were not contributory, and the patient was referred for a whole-body bone scan, which demonstrated multifocal osseous lesions, including such lesions in the lower legs, skull and facial bones. Magnetic resonance imaging (MRI) demonstrated numerous small tibial and fibular nodular lesions involving the medullary cavity and the cortex. A diagnosis of acquired syphilis was made, based on skin biopsy. Results of serological testing were consistent with recent infection. The patient was treated with intramuscular injection of penicillin, and follow-up MRI demonstrated gradual resolution of the osseous lesions. Bone involvement is a relatively rare manifestation of early acquired syphilis. Although the plain radiographic features of the bony changes in acquired syphilis are well documented, there have been no reports of the magnetic resonance imaging findings in the appendicular skeleton.

Significance of clinical evaluation of the metacarpophalangeal joint in relation to synovial/bone pathology in rheumatoid and psoriatic arthritis detected by magnetic resonance imaging.

OBJECTIVE: Rheumatologists base many clinical decisions regarding the management of inflammatory joint diseases on joint counts performed at clinic. We investigated the reliability and accuracy of physically examining the metacarpophalangeal (MCP) joints to detect inflammatory synovitis using magnetic resonance imaging (MRI) as the gold standard. METHODS: MCP joints 2 to 5 in both hands of 5 patients with rheumatoid arthritis (RA) and 5 with psoriatic arthritis (PsA) were assessed by 5 independent examiners for joint-line swelling (visually and by palpation); joint-line tenderness by palpation (tender joint count, TJC) and stress pain; and by MRI (1.5 Tesla superconducting magnet). Interrater reliability was assessed using kappa statistics, and agreement between examination and corresponding MRI assessment was assessed by Fisher's exact tests (p < 0.05 considered statistically significant). RESULTS: Interrater agreement was highest for visual assessment of swelling (kappa = 0.55-0.63), slight-fair for assessment of swelling by palpation (kappa = 0.19-0.41), and moderate (kappa = 0.41-0.58) for assessment of joint tenderness. In patients with RA, TJC, stress pain, and visual swelling assessment were strongly associated with MRI evaluation of synovitis. Visual swelling assessment demonstrated high specificity (> 0.8) and positive predictive value (= 0.8). For PsA, significant associations exist between TJC and MRI synovitis scores (p < 0.01) and stress pain and MRI edema scores (p < 0.04). Assessment of swelling by palpation was not significantly associated with synovitis or edema as determined by MRI in RA or PsA (p = 0.54-1.0). CONCLUSION: In inflammatory arthritis, disease activity in MCP joints can be reliably assessed at the bedside by examining for joint-line tenderness (TJC) and visual inspection for swelling. Clinical assessment may have to be complemented by other methods for evaluating disease activity in the joint, such as MRI, particularly in patients with PsA.

Assessment of radiographic progression in the spines of patients with ankylosing spondylitis treated with adalimumab for up to 2 years.

INTRODUCTION: Ankylosing spondylitis (AS) is a chronic rheumatic disease associated with spinal inflammation that subsequently leads to progression of structural damage and loss of function. The fully human anti-tumor necrosis factor (anti-TNF) antibody adalimumab reduces the signs and symptoms and improves overall quality of life in patients with active AS; these benefits have been maintained through 2 years of treatment. Our objective was to compare the progression of structural damage in the spine in patients with AS treated with adalimumab for up to 2 years versus patients who had not received TNF antagonist therapy. METHODS: Radiographs from patients with AS who received adalimumab 40 mg every other week subcutaneously were pooled from the Adalimumab Trial Evaluating Long-Term Efficacy and Safety for Ankylosing Spondylitis (ATLAS) study and a Canadian AS study (M03-606). Radiographic progression from baseline to 2 years in the spine of adalimumab-treated patients from these two studies (adalimumab cohort, n = 307) was compared with an historic anti-TNF-naïve cohort (Outcome in AS International Study [OASIS], n = 169) using the modified Stoke AS Spine Score (mSASSS) method. RESULTS: mSASSS results were not significantly different between the adalimumab cohort and the OASIS cohort, based on baseline and 2-year radiographs. Mean changes in mSASSS from baseline to 2 years were 0.9 for the OASIS cohort and 0.8 for the adalimumab cohort (P = 0.771), indicating similar radiographic progression in both groups. When results for patients in the OASIS cohort who met the baseline disease activity criteria for the ATLAS and Canadian studies (OASIS-Eligible cohort) were analyzed, there was no significant difference in mean change in mSASSS from baseline to 2 years between OASIS-Eligible patients and adalimumab-treated patients; the mean changes in mSASSS were 0.9 for the OASIS-Eligible cohort and 0.8 for the adalimumab cohort (P = 0.744). CONCLUSIONS: Two years of treatment with adalimumab did not slow radiographic progression in patients with AS, as assessed by the mSASSS scoring system, when compared with radiographic data from patients naïve to TNF antagonist therapy.

Recurrent symptoms after shoulder instability repair: direct MR arthrographic assessment--correlation with second-look surgical evaluation.

PURPOSE: To retrospectively determine the accuracy of direct magnetic resonance (MR) arthrography of the shoulder in patients with recurrent or residual signs and/or symptoms of instability after prior instability repair, with surgical findings as the reference standard. MATERIALS AND METHODS: After institutional ethics review board approval was obtained and informed consent was waived, 40 patients (31 men, eight women; mean age, 28 years) with recurrent instability after previous instability repair who underwent direct shoulder MR arthrography before repeat surgery were studied. Two musculoskeletal radiologists reviewed direct MR arthrographic studies by using consensus agreement in a blinded fashion. MR assessment included evaluation of the labrum (overall, superior, anterior and anteroinferior, posterior and posteroinferior), rotator cuff, biceps tendon, articular cartilage, and presence or absence of a Hill-Sachs lesion. Mean interval between MR arthrography and repeat surgery was 6.2 months (range, 6 days to 36 months). Surgical reports were compared with MR arthrographic results, and accuracy, sensitivity, and specificity of direct MR arthrography were determined. RESULTS: Accuracy, sensitivity, and specificity, respectively, of direct MR arthrography in diagnosis of overall labral tears (n = 26) were 91.9%, 96.2%, and 81.8%; those of superior labral tears (n = 16) were 89.2%, 93.8%, and 85.7%; and those of anteroinferior tears (n = 17) were 91.9%, 100%, and 85%. Overall accuracy for detecting rotator cuff injury (n = 17) was 87.2% (sensitivity, 94.1%; specificity, 81.8%); accuracy for biceps injury (n = 7) was 95.7% (sensitivity, 85.7%; specificity, 100%); accuracy for glenoid and/or humeral articular cartilage abnormality (n = 15) was 76.2% (sensitivity, 73.3%; specificity, 83.3%); and accuracy for Hill-Sachs lesion (n = 14) was 93.3%. CONCLUSION: Direct MR arthrography is accurate (91.9%) for assessing labral pathologic conditions and other internal derangements of the shoulder in patients with recurrent or residual signs and/or symptoms after prior shoulder instability repair.

Validation of the spondyloarthritis research consortium of Canada magnetic resonance imaging spinal inflammation index: is it necessary to score the entire spine?

OBJECTIVE: The Spondyloarthritis Research Consortium of Canada (SPARCC) magnetic resonance imaging (MRI) spinal inflammation index has been developed to objectively measure inflammation in ankylosing spondylitis (AS) and to assess change in response to therapeutic intervention. Scoring of the entire spine limits feasibility and a scoring method that records inflammation in only the more severely affected spinal segments may improve feasibility without sacrificing performance. METHODS: MRI films of 68 patients with AS were assessed in random order by 2 blinded readers. Interreader reliability was assessed by intraclass correlation coefficient. Pre- and posttreatment MRI films of 29 patients randomized to placebo or anti-tumor necrosis factor alpha (anti-TNFalpha) therapy were read by readers blinded to chronology, and responsiveness was assessed by effect size and standardized response mean. The performance of scores based on 6, 8, 10, and all 23 spinal discovertebral units (DVU) was compared. RESULTS: The median number of affected spinal levels per patient was 6.0 and 62% of all affected levels were included when analysis was limited to only the 6 most severely affected levels per patient. Comparison of DVU scores that were limited to only the more severely affected DVU (6-, 8-, 10-DVU score) with scores for all 23 spinal DVU showed excellent interreader reliability for status and change scores (Spearman's correlation >0.90) as well as similar construct validity. Responsiveness to anti-TNFalpha therapy was greater when the more limited scoring methods were used and was greatest with the 6-DVU score. CONCLUSION: The SPARCC MRI spinal inflammation index performs better when analysis is limited to a maximum of 6 most severely affected levels compared with assessment of the entire spine. This should improve its feasibility in clinical trials and research.

Continued inhibition of radiographic progression in patients with psoriatic arthritis following 2 years of treatment with etanercept.

OBJECTIVE: Clinical and radiographic responses were evaluated in patients with psoriatic arthritis (PsA) treated for up to 2 years with etanercept. METHODS: Patients were previously randomized to receive placebo or etanercept in a double-blind study and chose to participate in the current open-label extension phase. All patients received etanercept 25 mg twice weekly. Radiographic progression was determined at baseline, 1 year, and 2 years using the Sharp method modified to include joints frequently affected in PsA. Arthritis and psoriasis responses were determined using American College of Rheumatology 20% (ACR20) improvement criteria, PsA response criteria (PsARC), and the psoriasis area severity index (PASI). RESULTS: Of 205 patients randomized, 169 entered open-label, and 141 [71 randomized to receive placebo (placebo/etanercept) and 70 randomized to receive etanercept (etanercept/etanercept)] had radiographic data available for analysis at 2 years. ACR20 criteria, PsARC, and PASI 50 criteria were met by 64%, 84%, and 62%, respectively, of etanercept/etanercept patients at the end of the 48-week open-label period. Placebo/etanercept patients achieved comparable results within 12 weeks that were sustained at 48 weeks (63%, 80%, and 73%). Radiographic progression was inhibited in the etanercept/ etanercept patients (mean adjusted change in total Sharp score of -0.38 from baseline to 2 yrs). In placebo/etanercept patients, disease progression was inhibited once patients began receiving etanercept (mean adjusted change of -0.22 from 1 year to 2 years). Adverse event rates were similar to those observed during randomized phase, with only one serious adverse event deemed possibly related to etanercept. CONCLUSION: These data demonstrate a sustained benefit of etanercept treatment, including inhibition of radiographic progression, in patients with PsA.

Clinical accuracy of fluoroscopic computer-assisted pedicle screw fixation: a CT analysis.

STUDY DESIGN: Observational cohort study with computerized tomography (CT) analysis of in vivo pedicle screw placement. OBJECTIVE: To evaluate the clinical accuracy of computer-assisted fluoroscopy for the placement of thoracic and lumbosacral (LS) pedicle screws. SUMMARY OF BACKGROUND DATA: Computer-assisted fluoroscopy is an adjunct for the placement of pedicle screws. METHODS: Postoperative CT of 360 titanium pedicle screws (281 LS [L1-S1]; 79 thoracic [T2-T12]) were independently assessed. All screws were placed using the FluoroNav system (Medtronic Surgical Navigation Technologies, Louisville, CO). The relative position of the screw to the pedicle was graded as follows: A = completely in; B = <2 mm breach; C = 2-4 mm breach; and D = >4 mm breach. If an osseous breach occurred, the direction of the breach was further classified. RESULTS: Eight-five percent of screws were completely contained within the pedicle. Fifty-five-pedicle breaches (25 medial; 30 lateral) occurred. Pedicle breaches were graded B in 13.1% (47 breaches), C in 1.9% (7), and D in 0.3% (1) of screws. Pedicle breach was significantly higher in the thoracic compared to the LS spine, 31.6% (25/79) and 10.6% (30/281), respectively (P < 0.0001). In the thoracic spine, 72% of pedicle breaches were lateral. In 49% of breaches, the screw diameter was larger than the pedicle diameter. None of the pedicle breaches were associated with neurologic or other clinical sequelae. CONCLUSIONS: The clinical pedicle breach rate in this study is comparable to those reported using conventional techniques with or without fluoroscopic assistance. FluoroNav appears to be a safe adjunct for the placement of thoracic and LS pedicle screws.

Etanercept treatment of psoriatic arthritis: safety, efficacy, and effect on disease progression.

OBJECTIVE: Etanercept has been shown to improve the articular and cutaneous manifestations of psoriatic arthritis (PsA). In this study, we further evaluated the safety, efficacy, and effect on radiographic progression of etanercept in patients with PsA. METHODS: Patients with PsA (n = 205) were randomized to receive placebo or 25 mg etanercept subcutaneously twice weekly for 24 weeks. Patients continued to receive blind-labeled therapy in a maintenance phase until all had completed the 24-week phase, then could receive open-label etanercept in a 48-week extension. Efficacy and safety were evaluated at 4, 12, and 24 weeks and at 12-week intervals thereafter. Radiographs of the hands and wrists were assessed at baseline and 24 weeks, at entry to the open-label phase, and after 48 weeks in the study. RESULTS: Etanercept significantly reduced the signs and symptoms of PsA and psoriasis. At 12 weeks, 59% of etanercept patients met the American College of Rheumatology 20% improvement criteria for joint response, compared with 15% of placebo patients (P < 0.0001), and results were sustained at 24 and 48 weeks. At 24 weeks, 23% of etanercept patients eligible for psoriasis evaluation achieved at least 75% improvement in the Psoriasis Area and Severity Index, compared with 3% of placebo patients (P = 0.001). Radiographic disease progression was inhibited in the etanercept group at 12 months; the mean annualized rate of change in the modified total Sharp score was -0.03 unit, compared with +1.00 unit in the placebo group (P = 0.0001). Etanercept was well tolerated. CONCLUSION: Etanercept reduced joint symptoms, improved psoriatic lesions, inhibited radiographic progression, and was well tolerated in patients with PsA.