Magnetic resonance arthrography accuracy in the detection of labral tears in young patients with chronic unstable shoulder: correlation with arthroscopy.

The aim of this study is to determine the diagnostic performance of Magnetic Resonance Arthrography (MRA) in evaluating lesions of the glenoid labrum, in young active patients with chronic unstable shoulder, compared to shoulder arthroscopy. We retrospectively considered 65 MRA examinations, performed between December 2011 and January 2018. Among them, thirty-five patients (31 men, 4 women; mean age, 27.3 years; range, 16-53 years; 4 patients with a previous arthroscopy of the same shoulder) underwent shoulder arthroscopy after MRA. Arthroscopic reports were collected and analyzed for the correlation with MRA results.

Evaluation of accuracy of bone cuts and implant positioning in total knee arthroplasty using patient specific instrumentation.

In the last years new surgical techniques are developing to improve prosthesis positioning, increasing clinical and functional results and reducing invasiveness. In this scenario patient-specific instrumentations have been introduced in order to enhance surgical accuracy and ease of implantation. The purpose of this study was to assess the compliance of the pre-operative planning data with bone resections measured intraoperatively and to evaluate prosthesis positioning in patients undergoing total knee arthroplasty (TKA) using an MRI-based pin-guides instrumentation. Thirty consecutive patients (20 women and 10 men) undergoing 30 total knee replacements (20 right- and 10 left-sided knees) were included in this study. The same cemented cruciate ligament sacrificing prosthesis (NexGen LPS, Zimmer, Warsaw, Indiana, USA) was implanted in all patients by a single surgeon using Patient-Specific Instruments (PSI, Zimmer, Warsaw, Indiana, USA). Femoral and tibial bone resections were measured using a manual caliper intra-operatively and compared with the corresponding pre-operative values. Each patient underwent A CT examination following surgery in order to investigate individual component positioning. None of the cases was converted from PSI technique to conventional TKA and adequate femoral and tibial bone cuts were performed without the need for intraoperative adjustments. Two outliers were detected among the intra-operative bone cuts measurements. In all patients the size of femoral and tibial prosthetic components, hypothesized at preoperative planning, was confirmed intra-operatively. Two outliers were detected among post-operative CT measurements as for components positioning. PSI system can assist in obtaining good component positioning with reduction of outliers. Despite the small number of patients, our data demonstrate the validity of this patient-specific pin-guides system in TKA and may support repeatable improvements in surgical accuracy. Level of evidence: IV.

Risk of fracture prevention in spina bifida patients: correlation between bone mineral density, vitamin D, and electrolyte values.

PURPOSE: The aim of our study was to investigate the relationship between bone mineral density (BMD), vitamin D, and electrolyte blood values in patients with spina bifida, to find a possible therapeutic regimen and an intervention to reduce the risk of fractures in this population. METHODS: BMD values were measured in 49 patients (32 females, 17 males; aged 14.1 ± 3.86 years; range 5-20 years) using dual-energy X-ray absorptiometry (DEXA) and were analyzed based on sex, the level of spinal involvement, vitamin D, and electrolyte values, physical activity, body mass index (BMI), and ambulatory status [patients were divided into three subgroups: full-time wheelchair (FTWC), limited ambulator (LA), and full-time ambulator (FTA)]. These data were analyzed considering sex-, age-, and BMD-matched values and compared with those of normal population. RESULTS: BMD was significantly lower in these patients compared with that in the general healthy population (Z-score: -1.2 ± 1.8); in particular, females had Z-score values significantly lower that of the males (Z-score: -2.43 ± 2.02; P < 0.0004). In FTWC subgroup, Z-score was lower than that of the other two subgroups (P < 0.009). Vitamin D values were significantly lower compared with those in the general healthy population (vitamin D spina bifida group: 14.6 ± 8.7 mg/dL; normal subjects: 35 ± 9.8 mg/dL; P < 0.001). Subjects with spina bifida showed hypophosphatemia (<3 mg/dL) because of the lower levels of vitamin D (3.1 ± 0.9 mg/dL; P < 0.001). CONCLUSIONS: Spina bifida patients showed lower BMD, vitamin D, and electrolyte values than the healthy population; hence, they have an increase risk of developing pathological fractures. Vitamin D supplementation for a longer time period could reduce this risk.

Imaging of chondrocalcinosis: calcium pyrophosphate dihydrate (CPPD) crystal deposition disease -- imaging of common sites of involvement.

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is characterised by the accumulation of pyrophosphate dihydrate crystals in articular and periarticular tissues and it can be classified as sporadic, hereditary or secondary. The diagnosis frequently rests on radiographic findings. Computed tomography scanning can detect well mineralised deposits in joints and also ultrasound may be useful in detecting CPPD crystal deposits. About MRI recent studies have demonstrated the utility of high field in depiction of CPPD crystal deposits. The aim of this review is to focus on the clinical-classificative and radiological aspects of CPPD, particularly the contribution of the different imaging techniques.

Imaging of spondylodiscitis.

BACKGROUND: Spinal infections (pyogenic or non-pyogenic) are increasing in incidence and are a common cause of morbidity in high-risk patients (elderly, immunocompromised patients, diabetic patients, drug addicts, and patients with sickle-cell disease). AIM: To provide an overview of the radiological features of spinal infections, focusing on magnetic resonance (MR) imaging, and to illustrate the differential diagnosis. MATERIALS AND METHODS: We reviewed the spine imaging of 118 patients with spinal infections from our files. All patients underwent radiography and MR imaging examinations. computed tomography (CT) was performed in 96 patients. RESULTS: MR imaging has greatly contributed to prompt diagnosis, thus allowing implementation of timely appropriate treatment. CONCLUSIONS: Prompt diagnosis and treatment are essential to prevent serious bone and joint destruction, and severe neurologic sequelae.

The role of imaging in the pre- and postoperative evaluation of posterior occipito-cervical fusion.

PURPOSE: Occipitocervical fusion is required when the occipitoatlantal joint is unstable. The purpose of this paper is to discuss the role of imaging in the pre- and postoperative evaluation of posterior occipitocervical fusion (POCF), focusing on contoured loop fixation by Hartshill and Songer instrumentation. MATERIALS AND METHODS: We studied 21 patients (eight males, 12 females; age range 6-70 years; mean age 32.6 years) with craniocervical instability who underwent POCF with Hartshill U-shaped rod and Songer sublaminar wires. Pre- and postoperative radiographic, computed tomography (CT) and magnetic resonance (MR) imaging examinations were performed in all patients. A 3- to 6-month period of external orthosis with halo vest, sterno-occipitalmandibular immobiliser (SOMI) brace or Philadelphia collar followed surgery. Follow-up was 12-96 (mean 53.1) months. RESULTS: Clinical assessment using the Frankel scale revealed improvement or deterioration arrest in all but two patients: one with C3 failure and halo destabilisation; the other, who had exhibited myelopathy signs on preoperative MR imaging and persistent basilar impression, showed increasing and progressive neurological deficits despite successful POCF. CONCLUSIONS: Pre- and postoperative imaging is extremely useful in patients scheduled to undergo POCF. Preoperative MR screening of basilar impression associated with possible spinal cord lesions appears mandatory to predict possible deterioration and prevent undesired failure of the operation and it may suggest the need for an alternative surgical approach, such as the transoral approach.

Comparison between 2D and 3D computed tomography evaluation of glenoid bone defect in unilateral anterior gleno-humeral instability.

PURPOSE: This study evaluated the agreement between 2D and 3D computed tomography (CT) measurements in identifying the size and type of glenoid-bone defect in anterior glenohumeral instability. MATERIALS AND METHODS: One hundred patients affected by unilateral anterior glenohumeral instability underwent a CT of both shoulders. Images were processed with both 2D [multiplanar reconstruction (MPR)] and 3D [volumerendering (VR)] methods. The area of the missing glenoid was calculated in comparison with the healthy glenoid and expressed as a percentage. Agreement between the two measurements was assessed according to the Bland-Altman method; a 5% mean difference was considered as clinically relevant. RESULTS: Analysis of agreement between MPR and VR measurements of the percentage of missing glenoid showed a mean difference equal to 0.62%±1.96%. Percent agreement between the two measurements in detecting the presence of bone defect was 97% (p<0.0001). Percent agreement between the two measurements in discriminating the type of bone defect was 97% (p<0.0001). CONCLUSIONS: Agreement between 2D (MPR) and 3D (VR) CT measurements to identify the size and type of glenoid-bone defect in anterior glenohumeral instability was so high that the two measurements can be considered interchangeable.

MR in the evaluation of new anterior cruciate ligament and tibial tunnel position: correlation with clinical and functional features.

PURPOSE: This study aimed to evaluate correlations between the position of the tibial tunnel, its alignment with the ligament-screw system, presence of intratunnel fluid, position of the tibial tunnel with respect to the Blumensaat line and clinical knee stability in patients who underwent arthroscopic reconstruction of the anterior cruciate ligament (ACL), by using magnetic resonance (MR) imaging. MATERIALS AND METHODS: Forty-eight patients (40 men, eight women; mean age, 31 years) underwent arthroscopic reconstruction of the ACL using double-strand semitendinosus and gracilis tendons. The new ACL was fixed to the tibial tunnel using Bio-Intrafix (Mitek). All patients underwent MR imaging 12 months after surgery and clinical evaluation at 6 and 12 months using the International Knee Documentation Committee (IKDC) scoring system. MR imaging and clinical features were correlated using the Mann-Whitney U test for continuous variables and Fisher's exact test for categorical variables. RESULTS: Forty-one patients were clinically stable (groups A and B according to the IKDC test) and seven were unstable (group C). Mean values of tibial tunnel position in clinically unstable vs stable patients were, respectively, -3.6 ±3.8 mm vs. -2.8±3.8 mm in relation to the Blumensaat line (p=0.5712) and 77.3°±11.3 vs. 72.5°±5.5 as concerned the angle measured on the coronal view of the new ACL (p=0.3248); fluid was present in the tibial tunnel in 42.9% and 9.8% of cases, respectively (p=0.2104). MR imaging showed misalignment of ligament screw and tibial tunnel in 57.1% of patients in group C and in 12.2% in groups A and B (p=0.017). CONCLUSIONS: Misalignment of the ligament-screw system and the tibial tunnel and the presence of fluid in the tibial tunnel appear to be directly correlated with clinical instability.

Imaging of giant cell tumour of the tendon sheath.

Giant cell tumours of the tendon sheath (GCTTS) and pigmented villonodular synovitis (PVNS) are part of a spectrum of benign proliferative lesions of synovial origin that may affect the joints, bursae and tendon sheaths. This review article describes the clinicopathological features and imaging findings in patients with GCTTS. GCTTS usually presents as a soft tissue mass with pressure erosion of the underlying bone. Magnetic resonance (MR) imaging of GCTTS typically shows low to intermediate signal on T1- and T2-weighted spin-echo sequences due to the presence of haemosiderin, which exerts a paramagnetic effect. On gradient-echo sequences, the paramagnetic effect of haemosiderin is further exaggerated, resulting in areas of very low signal due to the blooming artefact. Ultrasonography shows a soft mass related to the tendon sheath that is hypervascular on colour or power Doppler imaging.

MR imaging of atlantoaxial joint in early rheumatoid arthritis.

PURPOSE: This study was done to assess the involvement of the atlantoaxial joint in patients with early rheumatoid arthritis and evaluate the role of magnetic resonance (MR) imaging in depicting this early joint involvement. MATERIALS AND METHODS: Twenty patients (16 women and four men, mean age 55.0±12.9 years) with clinical and laboratory evidence of early rheumatoid arthritis (mean disease duration <12 months) were included in our study. MR imaging of the atlantoaxial joint was performed in all patients within 3 months from diagnosis. The MR features were correlated with clinical and biochemical variables. RESULTS: Five (25.0%) of the 20 patients exhibited enhancement of the periodontoid synovial spaces after gadolinium administration due to inflammatory synovitis. Compared with patients without cervical involvement, these five patients showed significantly higher values of erythrocyte sedimentation rate [median 77.0 mm/h (range 25th and 75th percentile 69.0-86.0) vs median 33.0 mm/h (range 25th and 75th percentile: 9.2-52) (p=0.007)]; significantly higher C-reactive protein values [median 53.6 mg/l (range 25th and 75th percentile 21.9-81.9) vs median 14.0 mg/l (range 25th and 75th percentile 0.8-20) (p=0.03)]; higher disease activity score [median 4.2 (range 25th and 75th percentile 3.9-5.4) vs median 3.2 (range 25th and 75th percentile 2.8-3.8) (p=0.03)]. Four (80%) of these five patients presented anti-citrulline antibodies (anti-CCP) and rheumatoid factor at laboratory testing. The latter was positive in 12 of the 20 patients (66%), and anti-CCP were positive in 15 (83%). CONCLUSIONS: MR imaging showed an atlantoaxial inflammatory synovitis in 25% of patients with early rheumatoid arthritis. Our results indicate that patients with higher disease activity are likely to be at higher risk of presenting early involvement of the atlantoaxial joint. MR imaging of the cervical spine is an excellent tool for assessing the early manifestations of rheumatoid arthritis before any destructive changes occur. Therefore, MR imaging should be included in the diagnostic workup in order to provide reliable guidance for treatment choices.

Septic sacroiliitis: an uncommon septic arthritis.

Septic sacroiliitis is an uncommon joint infection and the diagnosis is often delayed. We present the first case of a septic arthritis of the shoulder and of the sacroiliac joint in a woman affected by systemic sclerosis, and we reviewed the medical literature since 1997 to 2008 on septic sacroiliitis with a specific microbiological diagnosis other than Mycobacteria and Brucella species.Evidence shows that antibiotic therapy should be continued until full clinical and radiological resolution is achieved.

Imaging of superficial and deep fibromatosis.

The purpose of this paper was to illustrate the role of diagnostic imaging in superficial and deep fibromatosis through a review of the use of different imaging modalities, including radiography, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), angiography and scintigraphy. In particular, in agreement with published data, it emphasises the crucial role of MRI as the primary modality providing the information needed for management decisions, preoperative planning and follow-up of these lesions.

Evaluation of magnetic resonance signal modification induced by hyaluronic acid therapy in chondromalacia patellae: a preliminary study.

Hyaluronic Acid (HA) is an alternative method for the treatment of osteoarthritis (OA), which acts on pain through a double action: anti-inflammatory and synovial fluid (SF) visco-supplementation. Magnetic Resonance Imaging (MRI), utilizing specific sequences, is a valid method for studying the initial phase of chondral damage. The analysis of the data, obtained through the intensity of values taken by positioning Region of Interest (ROIs) within the lesion, determining the differences before and after treatment with HA injected into the knee. The results obtained after six months and one year from the injection were statistically different in respect to those taken before, immediately and after three months of treatment. MRI represents a valid tool to evaluate the grade of chondromalacia patellae and also to follow the cartilage modification induced by HA therapy.

Diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) values for detection of malignant vertebral bone marrow lesions.

Malignant spinal bone marrow disorders are one of the major causes of significant morbidity and reduction in quality of life in oncological patients. Thus, the characterization of these conditions is of crucial importance in the management of these patients. Magnetic resonance (MR) imaging plays a vital role in differentiation between benign and malignant spinal bone marrow disorders. However, morphological imaging features, based on T1 and T2 relaxation properties, might fail in differentiating between these conditions because signal characteristics may overlap. Quantitative MR imaging based on diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) values has been proved to help in defining the nature of the lesion. The aims of this paper were: to review basic principles of DWI technique and ADC maps, to describe DWI and ADC maps appearances of normal vertebral bone marrow briefly, to discuss the DWI and ADC maps characteristics in vertebral malignant lesions, to provide indications for differential diagnosis between malignant and benign lesions.

Poly-L-lactic acid beta-tricalcium phosphate screws: a preliminary in vivo biocompatibility study.

The aim of this study is to assess the biocompatibility of two types of Poly-L-lactic acid (PLLA) screws (with either hydroxyapatite (HA) or beta-tricalcium phosphate (beta-TCP)) implanted in the left femur of four sheep euthanized at 42, 50, 57 and 84 days after surgery. Titanium screws were also implanted for comparison purposes. No signs of inflammation were seen in the 240 specimens. A rating of "+/-" for macrophages and "-" for neutrophils was assigned to all specimens. All specimens were assigned a rating which ranged from "+/-" to "+++" for fibroblasts and osteoblasts. The presence of macrophages, neutrophils and fibroblasts/osteoblasts was not statistically different for the four implantation periods. PLLA implants with beta-TCP have a biocompatibility comparable to PLLA implants with HA.

Clinical features, imaging findings, treatment aspects of elastofibroma dorsi and long-term outcomes after surgical resection.

OBJECTIVE: We aim to present clinical features, imaging findings, treatment aspects of the elastofibroma dorsi (ED), which is a benign tumor arising from connective tissue at the scapular region, and long-term outcomes after surgical resection. PATIENTS AND METHODS: We evaluated retrospectively 82 patients (55 females, 27 males; mean age, 60 years; age range, 23-78 years) with ED who underwent surgery between January 1994 and May 2014; subsequently all patients were invited for follow-up, which consisted of physical and US examinations. RESULTS: Subscapular location was almost constant (79/82 patients). Right, left and bilateral location was noted in 39, 28 and 15 cases, respectively. 52/82 patients were symptomatic. The diagnosis was made on physical examination and imaging studies: 49 ultrasound, 43 computed tomography and 54 magnetic resonance examinations were performed overall. Surgical treatment consisted in marginal excision; in all cases diagnosis was confirmed by histological examination. The mean hospitalization was 3 days, with minor complications. Out of the 82 patients, only 25 gave their consent to follow-up; mean time passed after surgery was 64.7 months; 1 case of local recurrence was suspected by ultrasound and, then, confirmed by magnetic resonance imaging. CONCLUSIONS: In our series, clinical features and imaging findings of ED are consistent with current evidence; however, results of our follow-up group marks a difference from the literature, according to which there is no evidence of local recurrence after complete resection. Diagnosis of ED is based on clinical and imaging features; treatment is surgical, especially in symptomatic cases. Prolonging the clinical and US follow-up period may be useful in identifying local recurrence.

MR angiography in carotid stenosis: a comparison of three techniques.

PURPOSE: To compare the accuracy of three different magnetic resonance angiography (MRA) techniques for studying steno-occlusive disease of carotid arteries. METHODS: 64 patients were evaluated with three MRA techniques- three-dimensional (3D) time-of-flight (TOF), two-dimensional (2D) TOF, and 3D Phase-Contrast (PC); the acquisition was in the axial plane, the volume included the carotid bifurcation. Digital subtraction angiography (DSA) was considered the 'gold standard'. The MRA images were reprojected with a maximum intensity pixel ray-tracing (MIP) algorithm. The three MRA techniques were blindly graded as normal, mildly stenotic (0-29%), moderately stenotic (30-49%), severely stenotic (70-99%), or occluded. RESULTS: DSA provided 128 diagnostic judgments: 92 were negatives and 36 positives. 2D TOF was in agreement with angiography in 116 of 128 cases (90%), but overestimated the results in seven cases and underestimated in five cases. 3D TOF agreed with angiography in 125 of 128 cases (97%), with one overestimation and two under estimations. 3D PC was concordant in 116 of 128 cases (90%), overestimating in six cases, underestimating in six cases. The sensitivity, specificity and diagnostic accuracy for 2D TOF was, respectively 84%, 94%, and 92%, while for 3D TOF was 94%, 100%, and 98%, and for 3D PC 86%, 98%, and 95%. The comparison of the three different MRA techniques provided no statistically significant difference (Friedman test P < 0.05). CONCLUSION: The high degree of diagnostic accuracy of MRA found in the study of the steno-occlusive disease of the carotid arteries confirms the high degree of reliability of this methodology carried out with the 3D TOF technique, compared to 2D TOF and 3D PC.

Superficial inflammatory and primary neoplastic lymphadenopathy: diagnostic accuracy of power-doppler sonography.

OBJECTIVE: To evaluate the sensitivity, specificity and diagnostic accuracy of a cut-off of the resistive index of 0.5 for the differentiation between inflammatory and neoplastic primary lymphadenopathies. SUBJECTS AND METHODS: We measured the resistive index of superficial enlarged lymph nodes in a total of 50 patients (29 males and 21 females; age range 12-72 years, mean age 41.6 year) using an ATL 5000 HDI. A resistive index greater than or equal to 0.5 indicated an inflammatory lymph node and a resistive index <0.5 was consistent with neoplastic primary lymphadenopathies. The gold standard was either surgical biopsy or lymph-node reduction seen with ultrasound examination after antibiotic therapy. RESULTS: The sensitivity of the resistive index for distinguishing inflammatory from neoplastic lymphadenopathy was 84.6%, the specificity 100% and the diagnostic accuracy 95.7% (P < 0.001, statistically significant). CONCLUSION: The results of this study indicate that power-Doppler using a resistive index cut-off of 0.5 was a valid technique for distinguishing between inflammatory and primary neoplastic lymph nodes in patients with superficial lymphadenopathies.

Carotid bifurcation stenosis: a comparative study between MR angiography and duplex scanning with respect to digital subtraction angiography.

PURPOSE: This study compared sensitivity, specificity and diagnostic accuracy of Echoduplex and Magnetic Resonance Angiography (MRA) in the evaluation of carotid bifurcation stenosis. MATERIAL AND METHODS: Twenty-five patients with clinical signs suggestive for cerebrovascular insufficiency (CVI) were studied with Duplex scan, MRA and Digital Subtraction angiography (DSA). Gold standard was the angiographic examination. RESULTS: on equal value of sensitivity (80.5%), MRA showed 96% specificity versus 81% of Duplex scan, 89.4% diagnostic accuracy versus 80.9% for Duplex scan. As for stenosis over 31%, the value of sensitivity did not change i.e., 80.5%; MRA showed 100% specificity versus 97.1% for Duplex, 91.2% diagnostic accuracy versus 89.1% respectively. These values compared by the test for categorial analysis and correspondence analysis (p < 0.05) did not indicate any statistically significant difference. DISCUSSION: on the basis of our experience and as shown by current literature [2, 12] we can state that both MR-angiography and Duplex scan fail in quantifying correctly carotid stenosis with consequent over- and underestimation [3, 4]. However, they can be considered effective diagnostic procedures in a screening program [12, 16]; they are accurate, safe and accepted by the population. CONCLUSIONS: on the basis of the cost in planning the screening of a population at risk for CVI, Duplex scanning is still to be considered the elective procedure.