Radiological characteristics of the calcaneal spurs in psoriatic arthritis.

OBJECTIVES: Inflammation at the entheses is a distinguishing feature of psoriatic arthritis (PsA). Enthesitis at the heel is the most common location at the Achilles and plantar fascia insertions on the calcaneus. This study aimed to 1) describe the morphological features and measurements of plantar calcaneal spurs in subjects with PsA and controls and 2) determine radiological features that differentiate between inflammatory and non-inflammatory calcaneal spurs. METHODS: Weight bearing lateral foot radiographs of 101 subjects with PsA and 38 control subjects without inflammatory arthritis were examined for plantar calcaneal and Achilles spurs. Three measurements were taken from each radiograph: plantar spur base, mid-segment, and length in millimeters. The differences in radiographic measurements, and the presence of fluffy periostitis of the plantar spurs were then compared between PsA patients and controls. RESULTS: Of the 101 subjects with PsA, 76 (75%) had at least one plantar calcaneal spur and 32 (31.5%) had at least one Achilles tendon spur, compared to 18 (47%) and 3 (8%) respectively in control group (p=0.004). Fluffy plantar periostitis was identified in 14 PsA subjects and none of the controls (p=0.01). The dimensions of plantar spurs were significantly different between groups - longer mid-segment distinguished patients with PsA from controls. CONCLUSIONS: Calcaneal spurs are more common in subjects with PsA than controls. Longer mid-segment measurement was associated with PsA. This study indicates that the presence of fluffy plantar periostitis and broad based and longer mid-segment dimensions are radiological features for inflammatory spurs.

Effect of adalimumab on joint disease: features of patients with psoriatic arthritis detected by magnetic resonance imaging.

BACKGROUND: Bone marrow oedema (BMO), synovitis, effusion and joint erosion on magnetic resonance imaging (MRI) may be used as outcome measures in psoriatic arthritis (PsA). OBJECTIVE: To assess the impact of adalimumab on BMO, synovitis, effusion and erosions in PsA, as measured by MRI. METHODS: Fifteen patients with active PsA (> or =3 tender and > or =3 swollen joints) were enrolled in an open-label pilot study. Each received adalimumab subcutaneously every other week for 24 weeks. MRI was obtained at baseline and 24 weeks. RESULTS: MRI was available for 11 patients, pre and post-therapy. BMO and effusion scores improved markedly after 24 weeks of adalimumab, while no significant change was noted in erosion score. An unanticipated finding, however, was the lack of improvement in the MRI synovitis score. CONCLUSIONS: Improvement in BMO and unchanged erosion scores may explain the "anti-erosive" effects of adalimumab in PsA. Persistence of BMO and synovitis on MRI suggests ongoing disease activity and supports the continuation of long-term anti-TNF therapy.

Rotator cuff evaluation: imaging and diagnosis.

A variety of disorders can lead to disease and pathology of the rotator cuff tendons. The most important information is obtained during a careful history and physical examination. With the judicious use of various diagnostic modalities, evaluation of the cause of the rotator cuff disease is possible.

Magnetic resonance imaging in pachydermoperiostosis.

Pachydermoperiostosis is a rare inherited disorder that is manifest clinically by digital clubbing, extremity enlargement, painful and swollen joints, hypertrophic skin changes, and periosteal bone formation. This report illustrates the skeletal findings that may be seen with long-standing disease as evaluated with conventional radiography and with magnetic resonance (MR) imaging, with emphasis on the MR appearance of periosteal reaction in this disorder. There are features that suggest pachydermoperiostosis may represent a generalized enthesopathy.

Inflammatory and degenerative sacroiliac joint disease in a primary back pain cohort.

OBJECTIVE: The prevalence of sacroiliac (SI) joint abnormalities in a primary low back pain population remains unresolved. The aims of our study were to define the prevalence of SI joint disease in this cohort, and to identify clinical features that might accurately predict radiographic changes in the SI joint and spine. METHODS: Lumbar spine and anteroposterior pelvis radiographs taken over a 3-year period for the evaluation of back pain at a major chiropractic college were scored for the presence of inflammatory or degenerative features. Data were subsequently extracted by means of a predetermined template from the clinical notes. The outcomes were correlated using Spearman's correlation coefficients. RESULTS: We identified 315 patients (173 men, 142 women), ages 18-60 years. Of these, 100 patients (31.7%) demonstrated SI joint abnormalities: 75 (23.8%) degenerative, 25 (7.9%) inflammatory. Sex was strongly associated with type of SI joint pathology; degenerative disease was predominantly found in women (68%), whereas inflammatory disease was predominantly found in men (63%). In women there was no correlation between degenerative SI joint abnormalities and degenerative changes in the lumbar spine. Of the clinical descriptors evaluated, none were associated with the radiographic findings with the exception of buttock pain, which was associated with inflammatory sacroiliitis. Neither being overweight nor pregnancy history was associated with degenerative changes in the SI joint. CONCLUSION: In a primary back pain cohort, degenerative SI joint disease may be an under-recognized clinical entity. It is strongly influenced by sex but is unrelated to degenerative changes in the lumbar spine. Currently proposed clinical discriminators performed poorly in correlating with radiographic changes in the SI joint.

Benign hidradenoma: magnetic resonance and ultrasound features of two cases.

Tumors of sweat gland origin are rare in the hand but should be considered in the differential diagnosis when certain imaging features are present. We present a case of nodular hidradenoma of the hand, with previously unreported magnetic resonance imaging features, and a further case in the thigh, both with ultrasound and histopathological correlation. The imaging literature of this tumor is reviewed, and its significance is discussed with respect to the current understanding of its malignant potential.

Compression of the deep palmar branch of the ulnar nerve by a ganglion : a case report.

A ganglion originating from the pisotriquetral joint is the most common cause of distal ulnar nerve compression. Midpalmar ganglions causing ulnar nerve compression are rare. This case describes a ganglion arising from the third carpometacarpal joint causing compression of the deep motor branch of the ulnar nerve.

Imaging of the seronegative spondyloarthropathies.

The group of seronegative spondyloarthropathies consists of ankylosing spondylitis, psoriatic arthritis, Reiter's disease, enteropathic spondylitis, and a fifth entity known as undifferentiated spondyloarthropathy. All of these diseases share common clinical and radiographic features with characteristic involvement of the sacroiliac joints, spine, and to various degrees, the peripheral joints. Although plain radiographs are the first line of imaging investigation, they are often insensitive for demonstrating the early changes of sacroiliitis, an important feature for establishing the early diagnosis of seronegative spondyloarthropathy. Other imaging modalities, including conventional tomography, bone scintigraphy, and computed tomography, have improved visualization of inflammatory changes at the sacroiliac joints. This article will review these modalities and emphasize the role of magnetic resonance imaging. By directly imaging changes in the synovium, articular cartilage, and subchondral bone, findings on magnetic resonance imaging are the most sensitive and specific for sacroiliitis and other changes in the axial skeleton. Its role and that of ultrasound in the assessment of the peripheral joints will also be highlighted.

Colonic aphthous ulcers in pseudomembranous colitis.

Colonic aphthous ulceration is usually due to Crohn's disease. It has been described in other colitides but has not been reported in pseudomembranous colitis. We report a patient with pseudomembranous colitis with aphthous ulceration demonstrated by barium examination.

Unilateral hemochromatosis arthropathy on a neurogenic basis.

We describe a 42-year-old man with right hemiplegia from cerebral palsy who presented with chronic left arm pain. Examination revealed 12 active joints, predominantly in the left hand. Radiographs showed characteristic changes of an advanced secondary osteoarthritic process in the left hand and only minimal changes on the right. Bone scan confirmed unilateral activity. Subsequent investigations diagnosed hemochromatosis. Unilateral arthropathy of hemochromatosis on a neurogenic basis has not been previously reported.

Posterolateral aspect of the knee: improved MR imaging with a coronal oblique technique.

PURPOSE: To determine if angling the coronal plane in magnetic resonance (MR) imaging of the knee increases the conspicuity of the posterolateral structures. MATERIALS AND METHODS: A coronal oblique MR imaging sequence performed parallel to the popliteal tendon proximally was added to our routine study in patient knee examinations. One hundred patients (age range, 12-72 years) underwent MR imaging. RESULTS: Coronal oblique images depicted the arcuate ligament in 46%, the fabellofibular ligament in 48%, and the fibular origin of the popliteal muscle in 53% of the patients, whereas standard coronal images depicted these in 10%, 34%, and 8% of the patients, respectively. Sagittal oblique images did not adequately depict these structures. CONCLUSION: Depiction of the structures in the posterolateral aspect of the knee was optimal on coronal oblique images. We advocate obtaining coronal oblique T2-weighted images in patients with either posterolateral knee pain or suspected injury to the posterolateral ligamentous structures.

Radiographic features of hepatocellular carcinoma and their relation to prognosis in Canada.

To determine the radiographic features of hepatocellular carcinoma (HCC) as seen in Canada and their relation to prognosis, multiple imaging studies for 40 patients with histologically proven HCC were reviewed. The patients, 34 men and 6 women ranging in age from 43 to 86 years, were selected from a larger database on the basis of the availability of ultrasound (US) images and at least one other imaging study. The patients had been examined between 1981 and 1991 at a tertiary-care hospital. In 35 of the 40 cases (88%) HCC had been detected by US assessment, the criterion for complete analysis, but in one of those cases the lesion was not observed in the initial scans. HCC was detected by computed tomography (CT) in the 27 cases in which that technique had been used. Cirrhosis was present in 27 of the 35 patients (77%) for which a complete analysis was performed. Median survival after diagnosis for all 40 patients was 14.1 weeks. Seven radiographic features were analysed for prognostic value by univariate and multivariate (Cox) regression analysis. However, the regression analysis indicated no relation between survival and tumour size, the nature of the tumour (diffuse and infiltrative or discrete), vascular involvement, encapsulation, extrahepatic spread, tumour location or echogenicity. No radiographic feature, including tumour size, correlated with the serum level of alpha-fetoprotein, which was elevated in 23 of the 32 cases (72%) in which it had been determined. These results confirm the variable radiographic appearance of HCC but differ in other respects from those reported previously, particularly those for studies performed outside North America.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiological assessment in psoriatic arthritis.

Our objective was to compare the reliability and responsiveness of the original Steinbrocker's (OS), our modified Steinbrocker's (MS) and Larsen's (L) radiological scoring methods for detecting radiological change in psoriatic arthritis over time. Two sets of radiographs of the hands and feet at least 2 yr apart were selected from 68 patients. Films were randomly presented and scored independently by a rheumatologist (DDG) and a radiologist (DS), in a blinded fashion using all methods. The index of reliability was the intraclass coefficient (ICC) and the responsiveness was assessed using plots and regression analyses. All three radiological scoring methods have excellent interobserver and good intra-observer reliability. L and MS are equally responsive and superior to OS in detecting change in joint damage over time. Thus, the L or MS radiological scoring methods can be used to monitor disease progression in psoriatic arthritis.

Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess.

PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in assessing the anterolateral recess of the ankle. MATERIALS AND METHODS: Thirty-two patients with chronic ankle pain prospectively underwent gadolinium-enhanced MR arthrography of the tibiotalar joint. All underwent clinical examination and were included if anterolateral impingement (n = 13) or a control condition (n = 19; suspected osteochondral defect, intraarticular bodies, instability, osteoarthritis) was diagnosed. MR imaging included transverse and coronal T1-weighted and sagittal T2-weighted imaging sequences. Images were prospectively analyzed by two readers blinded to the clinical diagnosis. The anterolateral gutter contour was assessed. MR arthrographic findings were correlated with subsequent arthroscopic appearances. RESULTS: MR arthrographic assessment of the anterolateral soft tissues had an accuracy of 97%, sensitivity of 96%, specificity of 100%, negative predictive value of 89%, and positive predictive value of 100%. Accuracy was 100% with clinical anterolateral impingement, with an arthroscopically confirmed abnormality in 12 cases and a normal appearance in one. Anterolateral soft-tissue thickening was identified at MR arthrography in 11 control cases, with arthroscopic confirmation in all. The remaining cases had normal appearances, with an arthroscopic soft-tissue abnormality in one case and a normal appearance in seven. CONCLUSION: MR arthrography of the tibiotalar joint is accurate in assessing the anterolateral recess of the ankle.

Clinical and imaging correlates of response to treatment with infliximab in patients with ankylosing spondylitis.

OBJECTIVES: Ankylosing spondylitis (AS) is a chronic disease leading to progressive spinal ankylosis and deformity. The aims of this study were to (1) determine whether infliximab is an effective treatment for AS patients who have failed conventional treatment; (2) identify any baseline clinical variables that can be associated with responsiveness to treatment; and (3) resolve whether the clinical response correlated with changes from baseline inflammatory changes on magnetic resonance imaging (MRI). METHODS: Twenty-one patients who met the modified New York criteria for AS (M:F 18:3) were enrolled in this open labeled study. The mean age was 37.9+/-7.9 years and mean disease duration was 8.69+/-6.58 years. Patients received infliximab at a dose of 5 mg/kg by intravenous infusion over 2 hours at 0, 2, 6, weeks. Nine functional variables were measured [i.e., Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI) etc.], 6 clinimetrics (chest expansion, finger to floor, etc.), and inflammatory markers in the peripheral blood at baseline and each subsequent visit. Primary response to treatment was defined as a > 20% response in 5/9 functional variables. A subset of 9 consecutive patients was selected for MRI scans before and after infusions. RESULTS: Eighteen patients were available for assessment at week 14 having received 3 infusions (wks 0, 2, 6). There was > 60% improvement in functional variables, i.e., BASDAI, BASFI, Health Assessment Questionnaire, fatigue, and spinal and total body pain. Clinimetric scores selectively improved, e.g., chest expansion (p < 0.021) by 14 weeks. ESR, CRP and haptoglobin all showed significant improvement at 6 weeks and were maintained to the 14 week assessment point. Imaging studies showed improvement in all patients studied including those with advanced disease. Three patients developed headache during the infusions. Infliximab was effective in all, but degree of response varied. Very good responders were distinguished from good responders by shorter duration of disease and better baseline clinimetric scores. CONCLUSIONS: Infliximab was an effective treatment for AS in a short term trial. Longterm control of symptoms and potential alteration in clinical course of disease will require longterm assessment.

Anteromedial impingement of the ankle: using MR arthrography to assess the anteromedial recess.

OBJECTIVE: Our objective was to describe the appearance of the anteromedial tibiotalar joint on MR arthrography in patients with clinically and arthroscopically confirmed anteromedial impingement. CONCLUSION: Anteromedial impingement of the ankle is now being recognized in the orthopedic literature as a distinct entity. MR arthrographic findings of anteromedial impingement include capsular and synovial soft-tissue thickening anterior to the tibiotalar ligaments and any associated osseous abnormality. Although anteromedial impingement is uncommon compared with other impingement syndromes of the ankle, the radiologist should be aware of the diagnosis and possible findings on cross-sectional imaging.

Complete dislocation of the knee: spectrum of associated soft-tissue injuries depicted by MR imaging.

OBJECTIVE: Complete knee dislocation is a rare injury. The purpose of this study was to evaluate the spectrum of injuries that are depicted by MR imaging in patients with a dislocation of the knee and to determine if there is any predictive factor that might indicate those patients who may be at risk for popliteal nerve injury. MATERIALS AND METHODS: A retrospective search for patients sustaining traumatic knee dislocations who had radiographs and an MR imaging examination of the knee as part of their initial evaluation was done at three level I trauma centers for the period between 1989 and 1993. Each MR examination was independently reviewed by three osteoradiologists for ligamentous, tendinous, meniscal, and osseous injuries. Equivocal diagnoses were decided by consensus. Only patients who underwent surgery were selected. MR imaging findings were confirmed at the time of surgery. Seventeen patients (15 men, two women; age range, 14-62 years; mean age, 29 years) were studied. Motor vehicle accident, fall from a height, a vehicle striking a pedestrian, and football injury were common mechanisms of injury. Posterior dislocation (seven patients) and anterior dislocation (five patients) were the most common injuries. RESULTS: At the time of surgery, all patients had complete tears of the anterior cruciate ligament, 15 had complete tears of the posterior cruciate ligament, nine had complete tears of the medial collateral ligament, and 12 had tears of the fibular collateral ligament (nine tore both the fibular collateral ligament and the biceps femoris tendon). Popliteal tendon tears occurred in eight patients (six complete, two partial). Of the six patients with complete tears of the popliteal tendon, five occurred at the musculotendinous junction; all were the result of either posterior or posterolateral dislocations. Four patients had injuries to the peroneal nerve; three of the four also had tears of the popliteal tendon. On MR imaging, the integrity of the anterior cruciate and lateral collateral ligaments was correctly depicted in all 17 patients; evaluation of the posterior cruciate ligament resulted in one false-positive and one false-negative diagnosis of a tear; evaluation of the medial collateral ligament resulted in one false-positive diagnosis of a tear; and one false-positive diagnosis of a tear occurred with evaluation of the popliteal tendon. CONCLUSION: Knee dislocations cause extensive disruption of the ligaments that stabilize the knee and the surrounding soft-tissue structures, including the popliteal artery. Nearly all will result in disruption of the cruciate ligments and, often, injury of the collateral ligaments. An injury to the popliteal tendon denotes a more severe injury. The mechanism of injury that results in a popliteal tendon tear may also increase the possibility of a peroneal nerve injury. Recognition of this pattern of injuries on MR imaging enables precautionary observation for ischemic changes of the foot to be instituted in patients that otherwise may not be considered at risk for acute vascular compromise.

Pictorial essay. MRI of the glenoid labrum with gross anatomic correlation.

The objective of this pictorial essay is to illustrate the magnetic resonance image (MRI) appearance of the glenoid labrum and the perilabral structures with and without instillation of intraarticular contrast material. Ten cadaveric shoulder specimens underwent axial MRI using various MR pulse sequences. The shoulders then were transversely sectioned, and the gross morphology of the labrum and perilabral structures was evaluated and correlated with the MR images. The contrast-enhanced sequences allowed for improved anatomic visualization of the structures evaluated.

Plantar compartments of the foot: MR appearance in cadavers and diabetic patients.

PURPOSE: To demonstrate the plantar compartments of the foot on magnetic resonance (MR) images. MATERIALS AND METHODS: The plantar compartments of four cadaveric feet underwent MR imaging and were sectioned. Fifteen MR studies in 11 patients with compartmental fluid were evaluated. The epicenter of infection was determined from review of the history, radiographs, and MR images. RESULTS: In the cadaveric feet, distribution of contrast material conformed to the compartmental anatomic features. MR findings in the specimen correlated exactly with gross findings. All seven feet with infection centered at the second through fourth metatarsal heads demonstrated only central compartment fluid. In seven of eight feet with a more medial or lateral epicenter of infection, fluid was seen in the lateral or medial compartment and in the central compartment. In one foot with a lateral epicenter of infection, fluid was confined to the lateral compartment. CONCLUSION: MR imaging accurately depicts the compartmental anatomic features of the foot.