Bone bruise distribution predicts anterior cruciate ligament tear location in non-contact injuries.

Purpose: It is unclear whether different injury mechanisms lead to divergent anterior cruciate ligament (ACL) tear locations. This study aims to analyse the relationship between bone bruise (BB) distribution or depth and ACL tear location. Methods: A retrospective analysis of 446 consecutive patients with acute non-contact ACL injury was performed. Only patients with complete ACL tears verified during subsequent arthroscopy were included. Magnetic resonance imaging (MRI) was used to classify BB location, BB depth, ACL tear location and concomitant injuries (medial/lateral meniscus and medial/lateral collateral ligament). Demographic characteristics included age, gender, body mass index (BMI), type of sport and time between injury and MRI. Multiple linear regression analysis was used to identify independent predictors of ACL tear location. Results: One hundred and fifty-eight skeletally mature patients met the inclusion criteria. The presence of BB in the lateral tibial plateau was associated with a more distal ACL tear location (ß = -0.27, p < 0.001). Less BB depth in the lateral femoral condyle showed a tendency towards more proximal ACL tears (ß = -0.14; p = 0.054). Older age predicted a more proximal ACL tear location (ß = 0.31, p < 0.001). No significant relationship was found between ACL tear location and gender, BMI, type of sport, concomitant injuries and time between injury and MRI. Conclusion: ACL tear location after an acute non-contact injury is associated with distinct patterns of BB distribution, particularly involving the lateral compartment, indicating that different injury mechanisms may lead to different ACL tear locations. Level of Evidence: Level III.

Nerve transfer reversal to treat co-contraction after anatomic brachial plexus reconstruction and Oberlin transfer: A case report.

Distal nerve transfers to restore elbow flexion have become standard of care in brachial plexus reconstruction. The purpose of this report is to draw attention to intractable co-contraction as a rare but significant adverse event of distal nerve transfers. Here we report of treatment of a disabling co-contraction of the brachialis muscle and wrist/finger flexors after median to brachialis fascicular transfer in a 61-year-old male patient. The primary injury was an postganglionic lesion of roots C5/C6 and a preganglionic injury of C7/C8 with intact root Th1 after a motor bicycle accident. After upper brachial plexus reconstruction (C5/C6 to suprascapular nerve and superior trunk) active mobility in the shoulder joint (supraspinatus, deltoid) could be restored. However, due to lacking motor recovery of elbow flexion the patient underwent additional median to brachialis nerve transfer. Shortly after, active elbow flexion commenced with rapid recovery to M4 at 9 months postoperatively. However, despite intensive EMG triggered physiotherapy the patient could not dissociate hand from elbow function and was debilitated by this iatrogenic co-contraction. After preoperative ultrasound-guided block resulted in preserved biceps function, the previously transferred median nerve fascicle was reversed. This was done by dissecting the previous nerve transfer of the median nerve fascicle to the brachialis muscle branch and adapting the fascicles to their original nerve. Postoperatively, the patient was followed up for 10 months without a complication and maintained M4 elbow flexion with independent strong finger flexion. Distal nerve transfers are an excellent option to restore function, however, in some patients cognitive limitations may prevent cortical reorganization and lead to disturbing co-contractions.

[Perioperative Diagnostics of Peripheral Nerve Lesions and Compression Syndromes: Position Paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels]. / Diagnostik von peripheren Nerven bei Läsionen und Kompressionssyndromen: Positionspaper der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie ­ (DAM).

The treatment of peripheral nerve pathologies requires a rapid and precise diagnosis. However, the correct identification of nerve pathologies is often difficult and valuable time is lost in the process. In this position paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels (DAM), we describe the current evidence for various perioperative diagnostics for the detection of traumatic peripheral nerve lesions or compression syndromes. In detail, we evaluated the importance of clinical examinations, electrophysiology, nerve ultrasound and magnetic resonance neurography. Additionally, we surveyed our members for their diagnostic approach in this regard. The statements are based on a consensus workshop on the 42nd meeting of the DAM in Graz, Austria.

Ultrasound of Small Nerves.

Nerve ultrasound has become an integral part of the diagnostic workup of peripheral neuropathies. Especially in the examination of small nerves, ultrasound provides superior image quality by using high frequency transducers. For a selection of small nerves, this article summarizes the local anatomy and common pathologies and offers simple instructions for determining their location with ultrasound including some cases with pathologies. This selection of nerves comprises the great auricular nerve, the supraclavicular nerves, the suprascapular nerve, the medial antebrachial cutaneous nerve, the lateral antebrachial cutaneous nerve, the palmar cutaneous branch of the median nerve, the long thoracic nerve, the intercostobrachial nerve, the posterior cutaneous nerve, the infrapatellar branch of the saphenous nerve, the medial calcaneal nerve, and the deep peroneal nerve at the ankle. Following our recommendations, these nerves can be swiftly located and tracked along their course to the site of the pathology.

[Evidence in Infiltrative Pain Therapy of the Musculoskeletal System]. / Evidenz in der infiltrativen Schmerztherapie des Bewegungsapparates.

Musculoskeletal pain symptoms frequently generate limitations in daily work and life in many patients. Usually, symptomatic treatment is possible before clarifying the in depth diagnosis. A symptom-based infiltration therapy will never replace a thoroughly done physical examination and thoughtful collection of patient history, however, it can be of great benefit for the patient when done focused on the point of pain and executed with profound anatomical knowledge. Furthermore, the knowledge of the level of evidence of therapeutic infiltrations improves their outcomes and shapes realistic patients' expectations. Ultrasound-guided therapeutic infiltrations improve the outcome despite the use of lower amounts of active agents by pinpointed applications. This article provides an overview of the scientific evidence of effectiveness of (ultrasound-guided) infiltration techniques in diverse musculoskeletal regions.

[Surgical management of peripheral nerves after extremity loss]. / Der chirurgische Umgang mit peripheren Nerven nach Extremitätenverlust.

BACKGROUND: After limb loss, it is the surgeon's task to provide the patient with a pain-free and resilient residual limb. Particularly in the upper extremity, there is an additional functional aspect, as appropriate muscle signals are needed to control myoelectric prostheses. Surgical management of peripheral nerves within the residual limb plays a central role both in terms of pain treatment as well as functional human-machine interfacing. OBJECTIVES: The presentation of current surgical procedures for dealing with peripheral nerves after limb amputation. MATERIAL AND METHODS: A literature search is carried out regarding the surgical prophylaxis and therapy of neuroma and phantom limb pain, as well as techniques to improve the functional interface between residual limb and prosthesis. Practical recommendations are formulated based on relevant literature, as well as the experiences of the authors. RESULTS AND CONCLUSIONS: There is a large number of different surgical techniques, particularly for the management of painful neuromas. Of the conventional methods, intramuscular implantation of the terminal nerves is commonly used with good results. Newer techniques such as targeted muscle reinnervation (TMR) and the regenerative peripheral nerve interface (RPNI) aim for the first time to provide functional end organs to the nerve even after amputation. In addition to the improved control of myoelectric prostheses, these methods further show excellent results for treatment and prevention of neuroma and phantom limb pain.

Neuralgic amyotrophy: a paradigm shift in diagnosis and treatment.

Neuralgic amyotrophy (NA), also known as Parsonage-Turner syndrome, is characterised by sudden pain attacks, followed by patchy muscle paresis in the upper extremity. Recent reports have shown that incidence is much higher than previously assumed and that the majority of patients never achieve full recovery. Traditionally, the diagnosis was mainly based on clinical observations and treatment options were confined to application of corticosteroids and symptomatic management, without proven positive effects on long-term outcomes. These views, however, have been challenged in the last years. Improved imaging methods in MRI and high-resolution ultrasound have led to the identification of structural peripheral nerve pathologies in NA, most notably hourglass-like constrictions. These pathognomonic findings have paved the way for more accurate diagnosis through high-resolution imaging. Furthermore, surgery has shown to improve clinical outcomes in such cases, indicating the viability of peripheral nerve surgery as a valuable treatment option in NA. In this review, we present an update on the current knowledge on this disease, including pathophysiology and clinical presentation, moving on to diagnostic and treatment paradigms with a focus on recent radiological findings and surgical reports. Finally, we present a surgical treatment algorithm to support clinical decision making, with the aim to encourage translation into day-to-day practice.

Pseudoerosions of Hands and Feet in Rheumatoid Arthritis: Anatomic Concepts and Redefinition.

Rheumatoid arthritis is a chronic inflammatory disease characterized by the development of osseous and cartilaginous damage. The correct differentiation between a true erosion and other entities-then often called "pseudoerosions"-is essential to avoid misdiagnosing rheumatoid arthritis and to correctly interpret the progress of the disease. The aims of this systematic review were as follows: to create a definition and delineation of the term "pseudoerosion", to point out morphological pitfalls in the interpretation of images, and to report on difficulties arising from choosing different imaging modalities. A systematic review on bone erosions in rheumatoid arthritis was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following search terms were applied in PubMed and Scopus: "rheumatoid arthritis", "bone erosion", "ultrasonography", "radiography", "computed tomography" and "magnetic resonance imaging". Appropriate exclusion criteria were defined. The systematic review registration number is 138826. The search resulted ultimately in a final number of 25 papers. All indications for morphological pitfalls and difficulties utilizing imaging modalities were recorded and summarized. A pseudoerosion is more than just a negative definition of an erosion; it can be anatomic (e.g., a normal osseous concavity) or artefact-related (i.e., an artificial interruption of the calcified zones). It can be classified according to their configuration, shape, content, and can be described specifically with an anatomical term. "Calcified zone" is a term to describe the deep components of the subchondral, subligamentous and subtendinous bone, and may be applied for all non-cancellous borders of a bone, thus representing a third type of the bone matrix beside the cortical and the trabecular bone.

Reliability of ultrasonography measurement of the anterior talofibular ligament (ATFL) length in healthy subjects (in vivo), based on examiner experience and patient positioning.

BACKGROUND: The most common cause of ankle injury is the supination trauma, inflicting a partial or complete rupture of the anterior talofibular ligament (ATFL). Among conventional diagnostic tools and procedures of sports injuries, the method of stress-ultrasonography is reportedly a promising diagnostic tool for examining injuries of the lateral ligaments of the ankle. Preceding studies predominantly examined the comparability of stress-ultrasonography and other established diagnostic tools in terms of efficacy, viability and quality. The purpose of this study was to assess the reliability of stress-ultrasonography of the ATFL based on varying examiner experience and patient positioning. METHOD: Sixteen healthy subjects were examined by four examiners with differing levels of skill and experience in ultrasonography, ranging from laymen to specialist. Measurements were recorded and interrater correlation coefficient (ICC) was applied in four positions, including a neutral position (A), medial rotation (B), plantar flexion (C) and inversion of the foot (D). RESULTS: The length of the ATFL was 14.958 ± 2.145 mm in position A, 15.886 ± 1.994 mm in position B, 16.270 ± 1.858 mm in position C and 15.170 ± 1.781 mm in position D. The average length change was 0.928 ± 0.804 mm (6.656 ± 6.299%) in position B, 1.313 ± 1.266 mm (9.746 ± 9.484%) in position C and 0.213 ± 1.807 mm (2.604 ± 12.308%) in position D. The correlation of the combined results of all four investigators was 0.333 for position A, 0.386 for position B, 0.320 for position C and 0.517 for position D. The highest ICC (0.811) was recorded between the orthopedic specialist and the radiology specialist. The lowest ICC (0.299) was recorded between the laymen and the radiology specialist. CONCLUSION: The reliability of the ATFL examination seems to be exceedingly dependent on the examiner's experience and skill in ultrasonographic (US) diagnostic. Moreover, the inversion positioning of the foot, described by the European Society of Musculoskeletal Radiology (ESSR) yielded the highest measurement reliability.

Ultrasound Anatomic Demonstration of the Infrapatellar Nerve Branches.

PURPOSE: To (1) confirm the correct identification of the infrapatellar branches of the saphenous nerve (IPBSNs) by high-resolution ultrasound (HRUS) with ink marking and consecutive dissection in anatomic specimens; (2) evaluate the origin, course, and end-branch distribution in healthy volunteers; and (3) visualize the variable anatomic course of the IPBSN by HRUS. METHODS: HRUS with high-frequency probes (15-22 MHz) was used to locate the IPBSN in 14 fresh anatomic specimens at 4 different locations. The correct identification of the IPBSN was verified by ink marking and consecutive dissection. Moreover, the IPBSNs were located in both knees of 20 healthy volunteers (n = 40). Their courses were marked on the volunteers' skin in a flexed-knee position. Distances were measured from the IPBSN branch closest to the median of the patella base (D1), center (D2), and apex (D3) and in a 45° (D4) and 0° (D5) relation to the median patella apex. Standardized photographs of all knees were mapped on 1 typically shaped knee. RESULTS: Dissection confirmed the correct identification of the IPBSN in 86% to 100% of branches, depending on their location. Intraindividual differences for distance measurements were observed for D1 (P < .001) and D2 (P = .002). The coefficient of variation was highest for D5 (0.86) and lowest for D1 (0.14). Mapping of the nerve branches on a typical knee showed a highly variable course for the IPBSN. CONCLUSIONS: This study confirmed the reliable ability to visualize the IPBSN and its variations with HRUS in anatomic specimens and in healthy volunteers; such visualization may therefore enhance the diagnostic and therapeutic management of patients with anteromedial knee pain. CLINICAL RELEVANCE: Ultrasound successfully pinpoints the variable course of the IPBSN from the origin to the most distal point and, therefore, may enable the correct identification of (iatrogenic) nerve damage in every location.

Multipath Curved Planar Reformations of Peripheral CT Angiography: Diagnostic Accuracy and Time Efficiency.

OBJECTIVES: To compare diagnostic performance and time efficiency between 3D multipath curved planar reformations (mpCPRs) and axial images of CT angiography for the pre-interventional assessment of peripheral arterial disease (PAD), with digital subtraction angiography as the standard of reference. METHODS: Forty patients (10 females, mean age 72 years), referred to CTA prior to endovascular treatment of PAD, were prospectively included and underwent peripheral CT angiography. A semiautomated toolbox was used to render mpCPRs. Twenty-one arterial segments were defined in each leg; for each segment, the presence of stenosis > 70% was assessed on mpCPRs and axial images by two readers, independently, with digital subtraction angiography as gold standard. RESULTS: Both readers reached lower sensitivity (Reader 1: 91 vs. 94%, p = 0.08; Reader 2: 89 vs. 93%, p = 0.03) but significantly higher specificity (Reader 1: 94 vs. 89%, p < 0.01; Reader 2: 96 vs. 95%, p = 0.01) with mpCPRs than with axial images. Reader 1 achieved significantly higher accuracy with mpCPRs (93 vs. 91%, p = 0.02), and Reader 2 had similar overall accuracy in both evaluations (94 vs. 94%, p = 0.96). Both readers read mpCPRs significantly faster than axial images (Reader 1: 5'45″ based on mpCPRs vs. 7'40″ based on axial images; Reader 2: 4'41″ based on mpCPRs vs. 6'57″ based on axial images; p < 0.01). CONCLUSIONS: mpCPRs are a promising 3D reformation technique that facilitates a fast assessment of PAD with high diagnostic accuracy.

Preoperative MRI is helpful but not sufficient to detect associated lesions in patients with chronic ankle instability.

PURPOSE: The aim of this study was to determine the reliability and validity of preoperative magnetic resonance imaging (MRI) scans for the detection of additional pathologies in patients with chronic ankle instability (CAI) compared to arthroscopic findings. METHODS: Preoperative MRI images of 30 patients were evaluated regarding articular and periarticular comorbidities and compared to intraoperative findings. The reliability of MRI was determined by calculating specificity, sensitivity, as well as positive and negative predictive values. The accuracy of the classification of cartilage lesions by Outerbridge and Berndt and Harty rating scales was determined by calculating the area under the receiver operating curve (AUC). RESULTS: In total, 72 additional pathologies were found arthroscopically compared to 73 lesions gathered from MRI images. Sensitivity ranged from 89% for peroneal tendinopathy to 28% for additional ligamentous lesions. Specificity ranged from 100% for anterolateral impingement, loose bodies and peroneal tendinopathy to 38% for additional ligamentous lesions. For cartilage lesions, sensitivity was at 91% and specificity was at 55% for the Outerbridge grading scale. For the Berndt and Harty classification system, sensitivity was at 91% and specificity was at 28%. Correlation of additional pathologies ranged from weak (r s = 0.48; p = 0.02) to moderate results (r s = 0.67; p < 0.001). CONCLUSION: CAI is associated with a high incidence of additional pathologies. In some cases, MRI delivers insufficient results, which may lead to misinterpretation of present comorbidities. MRI is a helpful tool for preoperative evaluation, but arthroscopy remains gold standard in the diagnosis of associated lesions in patients with CAI. LEVEL OF EVIDENCE: III.

A BMI-adjusted ultra-low-dose CT angiography protocol for the peripheral arteries-Image quality, diagnostic accuracy and radiation exposure.

OBJECTIVES: To investigate radiation exposure, objective image quality, and the diagnostic accuracy of a BMI-adjusted ultra-low-dose CT angiography (CTA) protocol for the assessment of peripheral arterial disease (PAD), with digital subtraction angiography (DSA) as the standard of reference. METHODS: In this prospective, IRB-approved study, 40 PAD patients (30 male, mean age 72 years) underwent CTA on a dual-source CT scanner at 80kV tube voltage. The reference amplitude for tube current modulation was personalized based on the body mass index (BMI) with 120 mAs for [BMI≤25] or 150 mAs for [2570%) was assessed by two readers independently and compared to subsequent DSA. Radiation exposure was assessed with the computed tomography dose index (CTDIvol) and the dosis-length product (DLP). Objective image quality was assessed via contrast- and signal-to-noise ratio (CNR and SNR) measurements. Radiation exposure and image quality were compared between the BMI groups and between the BMI-adjusted ultra-low-dose protocol and the low-dose institutional standard protocol (ISP). RESULTS: The BMI-adjusted ultra-low-dose protocol reached high diagnostic accuracy values of 94% for Reader 1 and 93% for Reader 2. Moreover, in comparison to the ISP, it showed significantly (p<0.001) lower CTDIvol (1.97±0.55mGy vs. 4.18±0.62 mGy) and DLP (256±81mGy x cm vs. 544±83mGy x cm) but similar image quality (p=0.37 for CNR). Furthermore, image quality was similar between BMI groups (p=0.86 for CNR). CONCLUSIONS: A CT protocol that incorporates low kV settings with a personalized (BMI-adjusted) reference amplitude for tube current modulation and iterative reconstruction enables very low radiation exposure CTA, while maintaining good image quality and high diagnostic accuracy in the assessment of PAD.

High-resolution ultrasound visualization of the deep branch of the ulnar nerve.

INTRODUCTION: The value of imaging the deep branch of the ulnar nerve (DBUN) over its entire course has not been clarified. Therefore, this study evaluates the feasibility of visualizing the DBUN from its origin to the most distal point. METHODS: We performed high-resolution ultrasound (HRUS) with high-frequency probes (18-22 MHZ), HRUS-guided ink marking, and consecutive dissection in 8 fresh cadaver hands. In both hands of 10 healthy volunteers (n = 20), the cross-sectional area (CSA) was measured at 2 different locations (R1 and R2). RESULTS: The DBUN was clearly visible in all anatomical specimens and in healthy volunteers. Dissection confirmed HRUS findings in all anatomical specimens. The mean CSA was 1.8 ± 0.5 mm2 at R1 and 1.6 ± 0.4 mm2 at R2. DISCUSSION: This study confirms that the DBUN can be reliably visualized over its entire course with HRUS in anatomical specimens and in healthy volunteers. Muscle Nerve 56: 1101-1107, 2017.

High-resolution ultrasound visualization of the recurrent motor branch of the median nerve: normal and first pathological findings.

PURPOSE: To evaluate in a prospective study the possibility of visualization and diagnostic assessment of the recurrent motor branch (RMB) of the median nerve with high-resolution ultrasound (HRUS). MATERIALS AND METHODS: HRUS with high-frequency probes (18-22 MhZ) was used to locate the RMB in eight fresh cadaveric hands. To verify correct identification, ink-marking and consecutive dissection were performed. Measurement of the RMB maximum transverse-diameter, an evaluation of the origin from the median nerve and its course in relation to the transverse carpal ligament, was performed in both hands of ten healthy volunteers (n = 20). Cases referred for HRUS examinations for suspected RMB lesions were also assessed. RESULTS: The RMB was clearly visible in all anatomical specimens and all volunteers. Dissection confirmed HRUS findings in all anatomical specimens. Mean RMB diameter in volunteers was 0.7 mm ± 0.1 (range, 0.6-1). The RMB originated from the radial aspect in 11 (55%), central aspect in eight (40%) and ulnar aspect in one (5%) hand. Nineteen (95%) extraligamentous courses and one (5%) subligamentous course were detected. Three patients with visible RMB abnormalities on HRUS were identified. CONCLUSION: HRUS is able to reliably visualize the RMB, its variations and pathologies. KEY POINTS: • Ultrasound allows visualization of the recurrent motor branch of the median nerve. • Ultrasound may help clinicians to assess patients with recurrent motor branch pathologies. • Patient management may become more appropriate and targeted therapy could be improved.

Recommendations of the ESSR Arthritis Subcommittee on Ultrasonography in Inflammatory Joint Disease.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee on the use of ultrasonography (US) in rheumatic disease, focused on the examination of joints in the adult population. The recommended examination technique and protocols used in a radiologic work-up are discussed. The main US features that can lead to a final diagnosis in the most common rheumatic diseases are addressed. The differential diagnosis that should be considered at image interpretation is presented. The role of US in interventional procedures and clinically important recent developments is also discussed.

Successful Identification and Assessment of the Superior Cluneal Nerves with High-Resolution Sonography.

BACKGROUND: Low back pain is a disabling and common condition, whose etiology often remains unknown. A suggested, however rarely considered, cause is neuropathy of the medial branch of the superior cluneal nerves (mSCN)-either at the level of the originating roots or at the point where it crosses the iliac crest, where it is ensheathed by an osseo-ligamentous tunnel. Diagnosis and treatment have, to date, been restricted to clinical assessment and blind infiltration with local anesthetics. OBJECTIVE: To determine whether visualization and assessment of the mSCN with high-resolution ultrasound (HRUS) is feasible. STUDY DESIGN: Interventional cadaver study and case series. METHODS: Visualization of the mSCN was assessed in 7 anatomic specimens, and findings were confirmed by HRUS-guided ink marking of the nerve and consecutive dissection. Further, a patient chart and image review was performed of patients assessed at our department with the diagnosis of mSCN neuropathy. RESULTS: The mSCN could be visualized in 12 of 14 cases in anatomical specimens, as confirmed by dissection. Nine patients were diagnosed with mSCN syndrome of idiopathic or traumatic origin. Diagnosis was confirmed in all of them, with complete resolution of symptoms after HRUS-guided selective nerve block. LIMITATIONS: These findings are first results that need to be evaluated in a systematic, prospective and controlled manner. CONCLUSION: We hereby confirm that it is possible to visualize the mSCN in the majority of anatomical specimens. The patients described may indicate a higher incidence of mSCN syndrome than has been recognized. mSCN syndrome should be considered in patients with low back pain of unknown origin, and HRUS may be able to facilitate nerve detection and US-guided nerve block.