A Case of a Mirror Image Artifact in the Forearm.

Teaching point: To emphasize the importance of recognizing mirror image artifacts in musculoskeletal ultrasound to avoid misdiagnosis, unnecessary interventions, and additional diagnostic procedures that can lead to patient anxiety, increased healthcare costs, and potential harm.

Diagnostic accuracy of ultrasound and MR imaging in peroneal neuropathy: A prospective, single-center study.

INTRODUCTION/AIMS: Magnetic resonance imaging (MRI) findings in peroneal neuropathy are not well documented and the prognostic value of imaging remains uncertain. Upper limits of cross-sectional area (CSA) on ultrasound (US) have been established, but uncertainty regarding generalizability remains. We aimed to describe MRI findings of the peroneal nerve in patients and healthy controls and to compare these results to US findings and clinical characteristics. METHODS: We prospectively included patients with foot drop and electrodiagnostically confirmed peroneal neuropathy, and performed clinical follow-up, US and MRI of both peroneal nerves. We compared MRI findings to healthy controls. Two radiologists evaluated MRI features in an exploratory analysis after images were anonymized and randomized. RESULTS: Twenty-two patients and 38 healthy controls were included. Whereas significant increased MRI CSA values were documented in patients (mean CSA 20 mm2 vs. 13 mm2 in healthy controls), intra- and interobserver variability was substantial (variability of, respectively, 7 and 9 mm2 around the mean in 95% of repeated measurements). A pathological T2 hyperintense signal of the nerve was found in 52.6% of patients (50% interobserver agreement). Increased CSA measurements (MRI/US), pathological T2 hyperintensity of the nerve and muscle edema were not predictive for recovery. DISCUSSION: Imaging is recommended in all patients with peroneal neuropathy to exclude compressive intrinsic and extrinsic masses but we do not advise routine MRI for diagnosis or prediction of outcome in patients with peroneal neuropathy due to high observer variability. Further studies should aim at reducing MRI observer variability potentially by semi-automation.

Leg Pain From Periostitis as the First Clinical Manifestation of Large-Vessel Vasculitis: A Case Report.

We report a case of a 47-year-old woman with isolated periostitis of the lower leg as a first manifestation of large-vessel vasculitis. The diagnosis was first suspected when a second magnetic resonance imaging of the lower leg approximately 4 months after onset of shin pain showed edema near intramuscular vessels. Isolated periostitis is a very rare skeletal manifestation of systemic vasculitis and easily could be misdiagnosed. This case demonstrates that maintaining a broad differential diagnosis for a common presenting complaint such as localized leg pain is imperative. LEVEL OF EVIDENCE: V.

Rotator cuff healing after needling of a calcific deposit using platelet-rich plasma augmentation: a randomized, prospective clinical trial.

BACKGROUND: Arthroscopic needling of a rotator cuff calcification is a highly reliable operation in terms of pain relief and return of function. However, during the needling process, a cuff defect is created. Little is known about the evolution of this defect. METHODS: We conducted a prospective, randomized controlled clinical trial to investigate the evolution of the aforementioned defect and the role of platelet-rich plasma (PRP) augmentation in this healing process. Patients were randomized to either group 1 (PRP, n = 20) or group 2 (no PRP [control group], n = 20). Patients in group 1 received a perioperative PRP infiltration at the rotator cuff defect, whereas the control group did not. Patients were assessed clinically preoperatively and postoperatively at 6 weeks, 3 and 6 months, and 1 year. The Constant score, Simple Shoulder Test, and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) were used as outcome measures. The evolution of the cuff defect was evaluated on sonography at 3 and 6 months and with magnetic resonance imaging after 1 year. RESULTS: All patients improved significantly after surgery (P < .05). There was no difference in clinical outcome or rotator cuff healing between groups. We observed a high rate of persistent rotator cuff defects after 1 year in both groups. The presence of residual cuff defects did not influence the clinical outcome. CONCLUSION: Arthroscopic needling is an operation with a predictive, good clinical outcome. We found a high rate of persistent rotator cuff defects after 1 year. This study could not identify any beneficial effect of the addition of PRP on rotator cuff healing. LEVEL OF EVIDENCE: Level II; Randomized Controlled Trial; Treatment Study.

Chronic anterior shoulder dislocation: aspects of current management and potential complications.

Chronic unreduced anterior dislocations of the shoulder are rare. Arterial and neurological complications in chronic glenohumeral dislocations are even less frequent. We report three cases of old anterior shoulder dislocations. Open reduction is indicated for most chronic shoulder dislocations. Arterial lesions require urgent intervention with reconstruction. Conservative treatment is advised for most neurological complications.

The modified axillary view of the shoulder, a painless alternative.

BACKGROUND: In our department, axillary views of the shoulder in trauma patients are not performed on a routine base, but sometimes, they are ordered by the trauma surgeon. We usually perform an anteroposterior view of the shoulder, combined with a posterior and an anterior oblique view of the shoulder in trauma patients. Because the classical described axillary view of the shoulder is sometimes very painful for the patient, especially in patients with humeral fractures, we perform a less painful modified axillary view. METHODS: We now perform the axillary view with the patient standing upright and bending forward and we give a craniocaudal tube inclination between 30 and 45 degrees. Doing so, we also have an "axillary" view on the shoulder, but without harm for the patient. We performed a retrospective study in 103 patients with a modified axillary view and the additional value was checked. CONCLUSION: We conclude that the modified axillary view is useful in 30 patients for detection of Hill-Sachs lesions or evaluation for displacement or angulation in proximal humeral fractures.

Epithelioid hemangioma of bone: a potentially metastasizing tumor?

The case of a 15-year-old boy with a severe swelling of the 2nd toe in the left foot and a large swelling of the left inguinofemoral region is described. Histologic examination of the foot lesion showed a typical epithelioid hemangioma of bone that extended into the soft tissues, with a secondary location in the groin, suggestive of lymph node involvement. Subsequently, imaging also revealed swelling of iliac and para-aortic lymph nodes, which probably indicates further lymph node spread.. Besides the fact that epithelioid hemangioma of the toe has not been reported yet, our case showed a non-continuous localization, most likely in draining lymph nodes. This finding suggests metastatic disease, an event that is extremely rare for epithelioid hemangioma. As such, epithelioid hemangioma might be comparable to another benign vascular tumor, the retiform hemangioendothelioma, which occasionally metastasizes to the lymph nodes without systemic spread.

Osteochondritis dissecans of the humeral head: clinical and radiological findings.

Osteochondritis dissecans (OCD) is a common condition in the knee, the elbow and the talus. It is rarely diagnosed in the humeral head. We report the case of a young male patient with OCD of the right humeral head and discuss the clinical and radiographic findings.

T2 mapping of human femorotibial cartilage with turbo mixed MR imaging at 1.5 T: feasibility.

The feasibility of a high-spatial-resolution technique for mapping T1 and T2 in articular cartilage in the human knee was evaluated. The technique, turbo mixed magnetic resonance (MR) imaging, is based on a pulse sequence in which inversion-recovery and spin-echo measurements are interleaved. The sequence was first validated in a phantom experiment in which T1 and T2 values obtained with an accepted spectroscopic technique were correlated with those obtained by using a clinical magnetic resonance imager with the turbo mixed technique. T2 maps were obtained with turbo mixed imaging in 25 volunteers (17 men, eight women; mean age, 30.8 years; range, 23-45 years). A high correlation (r = 0.99) was found between T1 and T2 values obtained at spectroscopy and those obtained at turbo mixed imaging. Relative differences in the range of cartilage relaxation times between the two techniques were less than 20%. Turbo mixed imaging in human volunteers showed T2 cartilage relaxation times that corresponded with previously published data. Turbo mixed imaging, thus, is feasible for T2 mapping of cartilage.

Correlation between power Doppler ultrasonography and clinical severity in Achilles tendinopathy.

Twenty-five patients with chronic Achilles tendinopathy were clinically and ultrasonographically evaluated. A positive correlation existed between power Doppler ultrasonography (PDU) and tendon thickness (r=0.63, p<0.001) and patient's age (r=0.40, p<0.05). A negative correlation existed between PDU and a functional test (number of toe raises to pain) (r=-0.57, p<0.005) and one recorded item of the Victorian Institute of Sport Assessment Achilles score (VISA-A questionnaire, item 6: jumping capability) (r=-0.46, p<0.05). Three patients had no detectable blood flow on PDU. PDU of Achilles tendons does not seem to be strictly related to symptoms but rather to functionality and chronicity of tendinopathy as indicated by toe-raises testing, jumping capability, patient age and tendon thickening.

Cross-sectional outcome analysis of athletes with chronic patellar tendinopathy treated surgically and by extracorporeal shock wave therapy.

OBJECTIVE: To compare the outcome of chronic patellar tendinopathy treated surgically and by extracorporeal shock wave therapy. DESIGN: Cross-sectional outcome analysis. SETTING: University Hospital Pellenberg, Leuven, Belgium. PATIENTS AND INTERVENTIONS: Of a total of 27 patients (28 knees) with chronic patellar tendinopathy, 13 were treated surgically, and 14 (15 knees) received extracorporeal shock wave therapy. MAIN OUTCOME MEASUREMENTS: Functional outcome questionnaire: Victorian Institute of Sport Assessment score, Visual Analog Scale, and Roles and Maudsley classification. RESULTS: At an average of 6 months of follow-up, the mean Victorian Institute of Sport Assessment and Visual Analog Scale scores for the extracorporeal shock wave therapy group were 78.8 +/- 28.7 and 9 +/- 2, respectively, which improved to 83.9 +/- 28.6 and 9 +/- 2, respectively, at 22.1 months. The surgery group scored 70.7 +/- 22.2 points on the Victorian Institute of Sport Assessment at an average of 26.3 months of follow-up (p = 0.41 and p = 0.18) and 8 +/- 3 on the Visual Analog Scale (p = 0.14). In the extracorporeal shock wave therapy group, 5 (33%) patients rated their pain status at 22.1 months as excellent, 5 (33%) as good, 2 (13%) as fair, and 2 (13%) as poor. In the surgery group, 4 (33%) evaluated the result as excellent, 3 (25%) as good, 3 (25%) as fair, and 2 as poor (17%). CONCLUSIONS: Extracorporeal shock wave therapy shows a comparable functional outcome to surgery in a cross-sectional analysis of patients with chronic proximal patellar tendinopathy resistant to conservative treatment.

Correlation between clinicopathological features and karyotype in 100 cartilaginous and chordoid tumours. A report from the Chromosomes and Morphology (CHAMP) Collaborative Study Group.

The evaluation of chondroid lesions requires full integration of clinical, radiographic, and pathological data; tumour typing is often a challenge for the diagnostic pathologist. Although a variety of chromosomal abnormalities have been documented in chondroid lesions, the potential usefulness of cytogenetic analysis remains unclear. This study has critically reviewed and analysed 117 karyotyped samples from 100 patients with cartilaginous and chordoid tumours. Cases were selected based on successful chromosomal analysis and adequacy of clinical, radiographic, and pathological information. To ensure objective evaluation, the cytogenetic results were correlated in a double-blind setting with consensus diagnoses independently determined on each case, after complete review of the histological, radiographic, and clinical findings. Karyotypic aberrations were identified in 41/92 cartilaginous tumours (5/11 osteochondromas, 2/3 chondromyxoid fibromas, 0/4 chondroblastomas, 11/29 chondromas, 0/3 chondroid tumours of undetermined malignant potential, 22/40 chondrosarcomas and 1/2 miscellaneous cartilaginous lesions) and 5/8 chordomas. Complex karyotypic changes were a feature of malignant tumours (chondrosarcoma and chordoma) and of chondrosarcoma among cartilaginous tumours, where they correlated with high tumour grade. Among primary well-differentiated cartilaginous lesions of bone, the finding of an abnormal karyotype was consistently associated with a grade 1 chondrosarcoma diagnosis. Among karyotypically abnormal cartilaginous tumours, loss of distal 8q was associated with osteochondroma, +5 with synovial chondroma/chondromatosis and parosteal or soft tissue chondroma, alterations of chromosome arm 6q with chondromyxoid fibroma, +7 with bone chondrosarcoma, and 17p1 alterations with grade 3 chondrosarcoma. Alterations involving 12q13 characterized synovial chondroma/chondromatosis in the chondroma group and myxoid chondrosarcoma of bone in the chondrosarcoma group. In conclusion, cytogenetic abnormalities in chondroid lesions are common and are not randomly distributed. They are associated with malignancy/tumour grade as well as with specific diagnoses in many cases, and can therefore be of potential value for tumour typing.