Comparison between conventional CT and grayscale inversion CT images in the assessment of the post-operative spinal orthopaedic implants.

AIM: To compare the accuracy of the inverted greyscale CT versus the conventional CT in the assessment of post-operative spinal orthopaedic implants and osseous fusion. METHODS: 50 patients who had CT as part of their routine spinal implant follow up were evaluated for the presence of fusion, fracture and loosening with conventional CT and with greyscale inverted CT images. 3 independent observers assessed the images 2 months apart. Diagnostic performance (sensitivity and specificity) of the conventional and greyscale inversion images relative to the reference standard were calculated. Agreement with the reference standard was assessed using Cohen's kappa for conventional and greyscale inversion images. RESULTS: Correct classifications increased when using the greyscale inverted CT images for each reader compared to conventional CT images (40-46, 39 to 42 and 41 to 44 (out of 50)). Inverted images demonstrated better agreement with the reference standard than conventional grayscale images for assessment of fusion (kappa of 0.588 for inverted CT versus 0.484 for conventional CT) and loosening (kappa 0.386 for inverted versus 0.293 for conventional). Sensitivity was increased for assessment of fusion and loosening. McNemar's test performed for assessment of sensitivity differences showed statistical significance (p = 0.038 for fusion and p = 0.0313 for loosening). CONCLUSION: Greyscale inversion CT is a useful adjunct which has advantages (improved sensitivity and better agreement) over conventional CT imaging in cases of fusion and loosening of metallic implants following spinal instrumentation. We recommend the use of both the greyscale inversion CT images and conventional CT imaging when assessing post-operative spinal orthopaedic implants.

MRI assessment of anatomy and pathology of the iliofemoral ligament.

The iliofemoral ligament is strongest ligament of the body. We review the magnetic resonance imaging (MRI) appearances of the iliofemoral ligament, and discuss the disease entities that may affect this region.

MR imaging in the assessment of residual tumour following inadequate primary excision of soft tissue sarcomas.

The purpose of this retrospective study was twofold: firstly, to assess the ability of MR imaging in confirming/excluding the presence of residual tumour following inadequate primary excision of soft tissue sarcomas; and secondly, to assess the accuracy of the original radiologists report as compared with a retrospective review of the scan hard copy in confirming/excluding. A total of 111 cases were identified that fulfilled the inclusion criteria of inadequate primary surgery followed by a MR scan and subsequent wide re-excision of the surgical field. The gold standard for the assessment of the MR imaging studies was histological examination of the re-excision specimens. Histological examination revealed residual tumour in 63 (56.7%) cases. In 48 cases the residual tumour was classified macroscopic (maximum diameter >10 mm) and 15 cases microscopic (maximum diameter

Computed tomographic arthrography in the assessment of osteochondritis dissecans of the elbow.

Eleven cases of osteochondritis dissecans of the elbow are reviewed. Computed tomography (CT) accurately identified the abnormality, its extent and its precise location. Computed tomographic arthrography (CTA) allowed accurate delineation of the overlying cartilage in all cases, identifying cartilage defects in four patients, fissuring in two and cartilage thinning in a further two. In those patients who had plain CT, four were shown to have loose bodies, one of which was obscured by contrast medium at subsequent CTA. Two further patients with loose bodies were identified using CTA alone. The possible relevance of these findings to management is discussed.

Computed tomographic assessment of soft tissue abnormalities following calcaneal fractures.

Computed tomographic (CT) examinations of 50 acute calcaneal fractures were compared with a further series of 77 fractures in which the date of injury preceded the CT by 6 months or more. 42 (84%) of the fractures in the acute group and 55 (71%) in the chronic group were classified as intra-articular and they form the basis of this study. The alteration in the position of the peroneal tendons in the two groups was similar, with a 5% or less difference in each category. In the acute group the peroneal tendons were normally located in 40.4% of the cases, entrapped by bone in 11.9%, subluxed in 33.3% and dislocated in 14.2%. Structural abnormalities of the peroneal tendons and surrounding soft tissues were identified in 52.4% of the acute group and in 61.1% of the chronic group. The incidence of partial rupture of the peroneal tendons in the chronic group was approximately one third that in the acute group, but the low incidence of complete tendon rupture remained unchanged. The inference from these observations is that, in the majority of cases, partial peroneal tendon rupture is reversible, whereas complete rupture is not. Seven fractures were common to both series and from this limited group the identification of haemorrhage around the peroneal tendons in the acute phase was shown not to be related to the subsequent development of chronic stenosing tenosynovitis. Various abnormalities of the medial tendons of the hindfoot were identified in 17% of the acute group and in 18% of the chronic group. Following calcaneal fracture, CT in both the immediate post-fracture period and in the late phase can be used to detect and classify the soft tissue changes. The limitations of comparing the two groups in this study are discussed.

Real-time digital contrast enhancement and magnification in the assessment of acute elbow injuries.

The elbow is a common site of injury and missed fractures may lead to disability and litigation. An assessment was made of a commercially available desk-top digital contrast enhancement and magnification unit (DETECT system) in a series of 320 patients with an acute elbow injury. Five radiologists of varying experience independently viewed elbow radiographs on a conventional light-box, and subsequently using the digitizer, indicating the presence or absence of a fracture. The overall results demonstrated no difference in performance when using the unit, though small improvements in the confidence with which a definite diagnosis was made were observed. Assessment of soft tissues with the digitizer was less reliable.

Glenoid hypoplasia: assessment by computed tomographic arthrography.

Four cases of an uncommon congenital skeletal anomaly, isolated bilateral glenoid hypoplasia, are presented with discussion of the possible pathogenesis and clinical significance. Bilateral computed tomographic arthrography of the shoulder demonstrated thickening of the inferior glenoid cartilage in two cases. The technique was of value in the symptomatic shoulder revealing the location of a contrast medium filled cleft within the posterior cartilage in one case and the true configuration of the glenohumeral joint in the second case, when the degree of deformity had rendered plain radiographs and conventional arthrography uninterpretable.

Computed tomographic assessment of old calcaneal fractures.

Prolonged pain and disability are common complications of calcaneal fractures. A prospective study was conducted on the value of computed tomography (CT) in 63 patients with 73 calcaneal fractures sustained more than 6 months before. The fractures were classified from the initial plain radiographs, and the patients' current clinical condition assessed in terms of a "disability score". The mean disability scores (MDS) associated with the different types of fracture were correlated with the CT findings. The highest MDS was found in the intra-articular fracture group which comprised 71% of the series. In this group the MDS was increased in the presence of post-traumatic osteoarthrosis of the subtalar joint (61% of cases), involvement of the calcaneocuboid joint (39% of cases) and subluxation/dislocation of the peroneal tendons (47% of cases). Structural abnormalities of the peroneal tendons were associated with a higher MDS including chronic tenosynovitis (eight cases), chronic partial tendon rupture (eight cases), complete peroneus brevis tendon rupture (two cases) and scarring indicating stenosing tenosynovitis (14 cases). A similar spectrum of appearances affecting the medial tendons of the hindfoot was identified in eight cases. Direct CT measurements of the degree of comminution did not correlate well with the patients' MDS. In the patient with persistent symptoms, CT is of value in the later assessment of long-term complications by revealing abnormalities of the subtalar joints and adjacent tendons.

Real-time digital contrast enhancement and magnification in the assessment of scaphoid and other wrist injuries.

A study on the value of a commercially available desk-top digital magnifier-contrast enhancer (DETECT System) was made in a series of 550 patients presenting with an acute wrist injury. Four radiologists, of varying experience, independently reviewed the radiographs on a conventional lightbox and later with the digitizer. In the scaphoid series (350 cases), the performance of the two more experienced radiologists was marginally better with the digitizer, whereas the less experienced radiologists performed slightly worse. Overall the digitizer improved the confidence of the radiologists in diagnosing correctly the presence of a scaphoid fracture but, for the less experienced radiologists, this was at the expense of identifying normality. In the wrist series (200 cases), the use of the digitizer resulted in a minor increase in the true positive and decrease in the false negative observations, but this was offset by a concomitant minor increase in the false positive and decrease in the true negative categories. Evaluation of the soft-tissue planes around the wrist joint showed a limited value in the identification of a scaphoid fracture with an overall positive predictive value of 0.26. Correlation of soft-tissue changes and the presence or absence of a scaphoid fracture was slightly worse with the digitizer. Possible causes for the apparently poorer performance of the digitizer are discussed, as well as the relative merits and potential value of the unit.

Older populations, aging individuals and health for all.

Family planning and reduced infant mortality have led to an explosion in the number of elderly people. There are already 300 million people aged 65 and over and by the year 2000 there will be over 400 million, two-thirds or more of them in the developing countries. Great gaps still exist in our knowledge of health and disease in the elderly, of how best to prevent or treat illness among them, and of how to care for those who become dependent. Although the precise impact of aging on societies awaits clarification, governments will undoubtedly have to develop social and health policies so as to adapt equitably to the forces of change.

[Tumorous space occupying lesions of the scapula. An analysis of preoperative assessment of invasion]. / Tumoröse Raumforderungen der Skapula. Eine Analyse zur präoperativen Dignitätsbeurteilung.

The radiographic and histological morphology of 38 tumors lesions of the scapula are analyzed. Osteochondromas (n = 12), chondrosarcomas (n = 7), plasmacytomas (n = 4) and Ewing's sarcomas (n = 3) were the most frequent neoplasms. The radiographically determined growth rates allowed an estimate of the dignity in all cases. Benign lesions were only observed in the first five decades of life, and were mostly located in the scapular blade. Most tumors found in the acromion and in the glenoid region and all lesions diagnosed in the 6th to the 8th decades of life were malignant. In 63.2% of cases correct diagnosis of the type of lesion present was possible on radiographic examination.

Epidemiological approaches to disability in the elderly: from measurement to the projection of need.

Measures of disability, in the elderly as a proxy for autonomy, are essential for assessment of physical and mental wellbeing, estimates of needs for care of individuals and communities and for the planning of services. Such measures need to be combined with clinical information to complete the diagnosis for the individual. For groups, assessments are subject to the interactions of reported disability with age, social class and culture, even when using standardized questionnaires. These intervening variables, as well as the representatives of the groups sampled, must be considered when extrapolating the findings to the whole population and, particularly, in the forecasting of future disability patterns. Translation of disability measurements into needs for service, now and in the future, is a complex procedure further confounded by social expectations and professional judgement.

The graying of Israel--implications for health and the need for services.

This article provides a brief overview of the demographic transformation of Israel and its consequences as a background to the articles appearing in this issue. Measurements of the morbidity of the elderly and their use of health services are discussed together with the ways those differ from estimates of health status and activities of daily living. The use of epidemiological surveys in planning future services is described and the need to develop innovative models of integrated care based on the neighborhood and community is discussed.

Contributions of different lipoprotein fractions to variations in total cholesterol between Israeli origin groups and social classes.

Total cholesterol, triglycerides and high-density lipoprotein (HDL)-cholesterol were measured in 2,306 boys, 1,716 girls, 2,479 fathers and 2,822 mothers examined on Visit 1 of the Jerusalem Lipid Research Clinics Prevalence Study in 1976-79. Low-density lipoprotein (LDL)-cholesterol levels were estimated from the other three measurements. Using multiple regression analysis to control for body mass index, social class, season of the year and (in parents) age, we compared the three origin groups (Asian, North African and European, depending on the birthplace of the parents) with the Israeli-born group. In both fathers and mothers, the lower total cholesterol levels in the North African group, and to a lesser extent in the Asian, were explained mainly by lower LDL-cholesterol in these groups. In youngsters, the origin groups were characterized by differences not only in LDL-cholesterol, but also in other lipoprotein fractions. Social class in youngsters and mothers was associated mainly with the HDL-cholesterol fraction; in fathers it was associated only with triglycerides. Possible relationships of these findings to smoking, alcohol, exercise and female sex hormones are discussed.

Health status and use of health services as reported by the older residents of the Baka neighborhood, Jerusalem.

The large increase in the aging population in Israel, particularly of people over 75, requires the upgrading of health services and their integration into comprehensive social support systems, which will help reduce the need for admission to institutions for long-term care. In our study, interviews were conducted with 77% of the residents of the Jerusalem neighborhood of Baka aged 60 and over and the data were supplemented by partial information on a further 20%. Our findings are similar to those reported from other surveys of the aged in Israel and indicate a high degree of unmet health needs in this population. Many of the problems of the elderly relate more to their social and cultural backgrounds than to objective measures of morbidity and they can only be partially solved by classical health services, even efficient ones. There is an urgent need for the development of integrated health, social and community service and support systems to meet the needs of this rapidly growing community.