Interobserver Agreement and Performance of Concurrent AI Assistance for Radiographic Evaluation of Knee Osteoarthritis.

Background Due to conflicting findings in the literature, there are concerns about a lack of objectivity in grading knee osteoarthritis (KOA) on radiographs. Purpose To examine how artificial intelligence (AI) assistance affects the performance and interobserver agreement of radiologists and orthopedists of various experience levels when evaluating KOA on radiographs according to the established Kellgren-Lawrence (KL) grading system. Materials and Methods In this retrospective observer performance study, consecutive standing knee radiographs from patients with suspected KOA were collected from three participating European centers between April 2019 and May 2022. Each center recruited four readers across radiology and orthopedic surgery at in-training and board-certified experience levels. KL grading (KL-0 = no KOA, KL-4 = severe KOA) on the frontal view was assessed by readers with and without assistance from a commercial AI tool. The majority vote of three musculoskeletal radiology consultants established the reference standard. The ordinal receiver operating characteristic method was used to estimate grading performance. Light kappa was used to estimate interrater agreement, and bootstrapped t statistics were used to compare groups. Results Seventy-five studies were included from each center, totaling 225 studies (mean patient age, 55 years ± 15 [SD]; 113 female patients). The KL grades were KL-0, 24.0% (n = 54); KL-1, 28.0% (n = 63); KL-2, 21.8% (n = 49); KL-3, 18.7% (n = 42); and KL-4, 7.6% (n = 17). Eleven readers completed their readings. Three of the six junior readers showed higher KL grading performance with versus without AI assistance (area under the receiver operating characteristic curve, 0.81 ± 0.017 [SEM] vs 0.88 ± 0.011 [P < .001]; 0.76 ± 0.018 vs 0.86 ± 0.013 [P < .001]; and 0.89 ± 0.011 vs 0.91 ± 0.009 [P = .008]). Interobserver agreement for KL grading among all readers was higher with versus without AI assistance (κ = 0.77 ± 0.018 [SEM] vs 0.85 ± 0.013; P < .001). Board-certified radiologists achieved almost perfect agreement for KL grading when assisted by AI (κ = 0.90 ± 0.01), which was higher than that achieved by the reference readers independently (κ = 0.84 ± 0.017; P = .01). Conclusion AI assistance increased junior readers' radiographic KOA grading performance and increased interobserver agreement for osteoarthritis grading across all readers and experience levels. Published under a CC BY 4.0 license. Supplemental material is available for this article.

Diagnostic accuracy in axial spondyloarthritis: a systematic evaluation of the role of clinical information in the interpretation of sacroiliac joint imaging.

OBJECTIVES: Radiography and MRI of the sacroiliac joints (SIJ) are relevant for the diagnosis and classification of patients with axial spondyloarthritis (axSpA). This study aimed to evaluate the impact of clinical information (CI) on the accuracy of imaging interpretation. METHODS: Out of 109 patients referred because of suspicion of axSpA with complete imaging sets (radiographs and MRI of SIJ), 61 were diagnosed with axSpA (56%). Images were independently evaluated by three radiologists in four consecutive reading campaigns: radiographs and radiographs+MRI without and with CI including demographic data, SpA features, physical activity and pregnancy. Radiographs were scored according to the modified New York criteria, and MRIs for inflammatory and structural changes compatible with axSpA (yes/no). The clinical diagnosis was taken as reference standard. The compatibility of imaging findings with a diagnosis of axSpA (precision) before and after the provision of CI and radiologists' confidence with their findings (0-10) were evaluated. RESULTS: The precision of radiographs evaluation without versus with CI increased from 70% to 78% (p=0.008), and for radiographs+MRI from 81% to 82% (p=1.0), respectively. For CR alone, the sensitivity and specificity of radiologic findings were 51% and 94% without and 60% and 100% with CI, while, for radiographs+MRI, they were 74% and 90% vs 71% and 98%, respectively. The diagnostic confidence of radiologists increased from 5.2±1.9 to 6.0±1.7 with CI for radiographs, and from 6.7±1.6 to 7.2±1.6 for radiographs+MRI, respectively. CONCLUSION: The precision, specificity and diagnostic confidence of radiologic evaluation increased when CI was provided.

Learning imaging in axial spondyloarthritis: more than just a matter of experience.

OBJECTIVE: Reliable interpretation of imaging findings is essential for the diagnosis of axial spondyloarthritis (axSpA) and requires a high level of experience. We investigated experience-dependent differences in diagnostic accuracies using X-ray (XR), MRI and CT. METHODS: This post hoc analysis included 163 subjects with low back pain. Eighty-nine patients had axSpA, and 74 patients had other conditions (mechanical, degenerative or non-specific low back pain). Final diagnoses were established by an experienced rheumatologist before the reading sessions. Nine blinded readers (divided into three groups with different levels of experience) scored the XR, CT and MRI of the sacroiliac joints for the presence versus absence of axSpA. Parameters for diagnostic performance were calculated using contingency tables. Differences in diagnostic performance between the reader groups were assessed using the McNemar test. Inter-rater reliability was assessed using Fleiss kappa. RESULTS: Diagnostic performance was highest for the most experienced reader group, except for XR. In the inexperienced and semi-experienced group, diagnostic performance was highest for CT&MRI (78.5% and 85.3%, respectively). In the experienced group, MRI showed the highest performance (85.9%). The greatest difference in diagnostic performance was found for MRI between the inexperienced and experienced group (76.1% vs 85.9%, p=0.001). Inter-rater agreement was best for CT in the experienced group with κ=0.87. CONCLUSION: Differences exist in the learnability of the imaging modalities for axSpA diagnosis. MRI requires more experience, while CT is more suitable for inexperienced radiologists. However, diagnosis relies on both clinical and imaging information.

VEXAS and Myelodysplastic Syndrome: An Interdisciplinary Challenge.

VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently recognized systemic autoinflammatory disease caused by somatic mutations in hematopoietic progenitor cells. This case series of four patients with VEXAS syndrome and comorbid myelodysplastic syndrome (MDS) aims to describe clinical, imaging, and hematologic disease presentations as well as response to therapy. Four patients with VEXAS syndrome and MDS are described. A detailed analysis of imaging features, hemato-oncological presentation including bone marrow microscopy and clinical-rheumatological disease features and treatment outcomes is given. All patients were male; ages ranged between 64 and 81 years; all were diagnosed with MDS. CT imaging was available for three patients, all of whom exhibited pulmonary infiltrates of varying severity, resembling COVID-19 or hypersensitivity pneumonitis without traces of scarring. Bone marrow microscopy showed maturation-disordered erythropoiesis and pathognomonic vacuolation. Somatic mutation in the UBA1 codon 41 were found in all patients by next-generation sequencing. Therapy regimes included glucocorticoids, JAK1/2-inhibitors, nucleoside analogues, as well as IL-1 and IL-6 receptor antagonists. No fatalities occurred (observation period from symptom onset: 18-68 months). Given the potential underreporting of VEXAS syndrome, we highly recommend contemporary screening for UBA1 mutations in patients presenting with ambiguous signs of systemic autoinflammatory symptoms which persist over 18 months despite treatment. The emergence of cytopenia, especially macrocytic hyperchromic anemia, should prompt early testing for UBA1 mutations. Notably conspicuous, pulmonary alterations in CT imaging of patients with therapy-resistant systemic autoinflammatory symptoms should be discussed in interdisciplinary medical teams (Rheumatology, Hematology, Radiology and further specialist departments) to facilitate timely diagnosis during the clinical course of the disease.

Characterization of bone marrow lesions in axial spondyloarthritis using quantitative T1 mapping MRI.

OBJECTIVE: Conventional magnetic resonance imaging (MRI) uses T1-weighted and short-tau inversion recovery (STIR) sequences to characterize bone marrow in axial spondyloarthritis. However, quantification is restricted to estimating the extent of lesions because signal intensities are highly variable both within individuals and across patients and MRI scanners. This study evaluates the performance of quantitative T1 mapping for distinguishing different types of bone marrow lesions of the sacroiliac joints. MATERIALS AND METHODS: In this prospective study, 62 patients underwent computed tomography (CT) and MRI of the sacroiliac joints including T1, STIR, and T1 mapping. Bone marrow lesions were characterized by three readers and assigned to one of four groups: sclerosis, osteitis, fat lesions, and mixed marrow lesions. Relaxation times on T1 maps were compared using generalized estimating equations and receiver operating characteristics (ROC) analysis. RESULTS: A total of 119 lesions were selected (sclerosis: 38, osteitis: 27, fat lesions: 40; mixed lesions: 14). T1 maps showed highly significant differences between the lesions with the lowest values for sclerosis (1516±220 ms), followed by osteitis (1909±75 ms), and fat lesions (2391±200 ms); p<0.001. T1 mapping differentiated lesions with areas under the ROC curve of 99% (sclerosis vs. osteitis) and 100% (other comparisons). CONCLUSION: T1 mapping allows accurate characterization of sclerosis, osteitis, and fat lesions at the sacroiliac joint but only for homogeneous, non-mixed lesions. Thus, further sequence development is needed before implementation in clinical routine.

Inter-software and inter-threshold reliability of quantitative paraspinal muscle segmentation.

PURPOSE: Changes in the cross-sectional area (CSA) and functional cross-sectional area (FCSA) of the lumbar multifidus (MF) and erector spinae muscles (ES) are factors that can contribute to low back pain. For the assessment of muscle CSA and composition there are various software and threshold methods used for tissue segmentation in quantitative analysis. However, there is currently no gold standard for software as well as muscle segmentation. This study aims to analyze the measurement error between different image processing software and different threshold methods for muscle segmentation. METHODS: Magnetic resonance images (MRI) of 60 patients were evaluated. Muscle CSA and FCSA measurements were acquired from axial T2-weighted MRI of the MF and ES at L4/L5 and L5/S1. CSA, FCSA, and FCSA/CSA ratio were measured independently by two observers. The MRI images were measured using two different software programs (ImageJ and Amira) and with two threshold methods (Circle/Overlap method) for each software to evaluate FCSA and FCSA/CSA ratio. RESULTS: Inter-software comparisons revealed high inter-rater reliability. However, poor inter-rater reliability were obtained with different threshold methods. CSA, FCSA, and FCSA/CSA showed excellent inter-software agreement of 0.75-0.99 regardless of the threshold segmentation method. The inter-rater reliability between the two observers ranged between 0.75 and 0.99. Comparison of the two segmentation methods revealed agreement between 0.19 and 0.84. FCSA and FCSA/CSA measured via the Overlap method were significantly higher than those measured via the Circle method (P < 0.01). CONCLUSION: The present study showed a high degree of reliability with very good agreement between the two software programs. However, study results based on different threshold methods should not be directly compared.

New Bone Formation in Axial Spondyloarthritis: A Review.

BACKGROUND: Axial spondyloarthritis (axSpA) is a chronic inflammatory disease primarily affecting the sacroiliac joints (SIJs) and the spine. Imaging plays a crucial role in the diagnosis of axSpA, with magnetic resonance imaging (MRI) and radiography being the primary modalities used in clinical practice. New bone formation occurs in both the spine (non-bridging and bridging syndesmophytes, transdiscal ankylosis, and ankylosis of small joints and posterior elements) and the SIJs (backfill and ankylosis). New bone formation indicates advanced axSpA. METHOD: This review explores the role of imaging in the diagnosis and monitoring of axSpA, focusing on the significance of new bone formation, and provides an overview of the characteristic imaging findings of new bone formation in axSpA in each imaging modality. CONCLUSION: Imaging methods, such as X-ray, MRI, and CT, have different diagnostic accuracies for detecting structural lesions and new bone formation. Each modality has its strengths and weaknesses, and the choice depends on the specific clinical context. Imaging is crucial for the diagnosis and monitoring of axSpA, particularly for the detection of new bone formation. Different imaging techniques provide valuable information about disease progression and treatment response. Understanding the significance of new bone formation and its detection using imaging modalities is essential for the accurate diagnosis and effective management of patients with axSpA. KEY POINTS: · New bone formation is a hallmark feature of advanced axial spondyloarthritis.. · New bone formation occurs both in the spine and in the sacroiliac joints.. · Differentiation of new bone formation in axial spondyloarthritis from that in other conditions such as diffuse idiopathic skeletal hyperostosis and from osteophytes is essential.. · Imaging methods, such as X-ray, MRI, and CT, have different diagnostic accuracies for detecting new bone formation..

Mapping gender and geographic diversity in artificial intelligence research: Editor representation in leading computer science journals.

Background: The growing role of artificial intelligence (AI) in healthcare, particularly radiology, requires its unbiased and fair development and implementation, starting with the constitution of the scientific community. Purpose: To examine the gender and country distribution among academic editors in leading computer science and AI journals. Material and Methods: This cross-sectional study analyzed the gender and country distribution among editors-in-chief, senior, and associate editors in all 75 Q1 computer science and AI journals in the Clarivate Journal Citations Report and SCImago Journal Ranking 2022. Gender was determined using an open-source algorithm (Gender Guesser™), selecting the gender with the highest calibrated probability. Result: Among 4,948 editorial board members, women were underrepresented in all positions (editors-in-chief/senior editors/associate editors: 14%/18%/17%). The proportion of women correlated positively with the SCImago Journal Rank indicator (ρ = 0.329; p = .004). The U.S., the U.K., and China comprised 50% of editors, while Australia, Finland, Estonia, Denmark, the Netherlands, the U.K., Switzerland, and Slovenia had the highest women editor representation per million women population. Conclusion: Our results highlight gender and geographic disparities on leading computer science and AI journal editorial boards, with women being underrepresented in all positions and a disproportional relationship between the Global North and South.

Self-reported diagnostic confidence predicts diagnostic accuracy in axial spondyloarthritis imaging.

OBJECTIVES: Reporting diagnostic confidence (DC) in axial spondyloarthritis (axSpA) imaging is recommended by the ASAS guidelines. Our aim was to investigate whether self-reported DC predicts diagnostic accuracy in axSpA imaging using X-ray (XR), computed tomography (CT) and magnetic resonance imaging (MRI). METHODS: We performed a post hoc analysis including 163 patients with low back pain (89 axSpA and 56 non-axSpA). Nine blinded readers with different experience levels (inexperienced (< 1 year), semi-experienced (3-8 years) and experienced (> 12 years)) scored the sacroiliac joint images for compatibility with axSpA. DC was reported on a scale from 1 (not sure) to 10 (very sure). Mean DC scores and standard deviations were calculated for correct and incorrect responses using XR, CT, MRI, XR+MRI and CT+MRI. Differences in DC were assessed using the Mann-Whitney U test. RESULTS: DC scores were higher for correct axSpA diagnoses and differed significantly between correct and incorrect responses for all modalities (p< 0.001), with a mean DC of 7.1 ± 2.1 and 6.3 ± 2.1 for XR, 8.3 ± 1.8 and 6.7 ± 2.0 for CT, 8.1 ± 1.9 and 6.2 ± 1.9 for MRI, 8.2 ± 1.8 and 6.7 ± 1.8 for XR+MRI and 8.4 ± 1.8 and 6.8 ± 1.8 for CT+MRI, respectively. This was also the case when looking at the results by experience group, except for XR in the inexperienced group. CONCLUSION: Providing self-reported DC in radiological reports is useful information to predict diagnostic reliability in axSpA imaging.

Artificial intelligence to analyze magnetic resonance imaging in rheumatology.

Rheumatic disorders present a global health challenge, marked by inflammation and damage to joints, bones, and connective tissues. Accurate, timely diagnosis and appropriate management are crucial for favorable patient outcomes. Magnetic resonance imaging (MRI) has become indispensable in rheumatology, but interpretation remains laborious and variable. Artificial intelligence (AI), including machine learning (ML) and deep learning (DL), offers a means to improve and advance MRI analysis. This review examines current AI applications in rheumatology MRI analysis, addressing diagnostic support, disease classification, activity assessment, and progression monitoring. AI demonstrates promise, with high sensitivity, specificity, and accuracy, achieving or surpassing expert performance. The review also discusses clinical implementation challenges and future research directions to enhance rheumatic disease diagnosis and management.

Sex-specific diagnostic efficacy of MRI in axial spondyloarthritis: challenging the 'One Size Fits All' notion.

OBJECTIVES: Sex-specific differences in the presentation of axial spondyloarthritis (axSpA) may contribute to a diagnostic delay in women. The aim of this study was to investigate the diagnostic performance of MRI findings comparing men and women. METHODS: Patients with back pain from six different prospective cohorts (n=1194) were screened for inclusion in this post hoc analysis. Two blinded readers scored the MRI data sets independently for the presence of ankylosis, erosion, sclerosis, fat metaplasia and bone marrow oedema. Χ2 tests were performed to compare lesion frequencies. Contingency tables were used to calculate markers for diagnostic performance, with clinical diagnosis as the standard of reference. The positive and negative likelihood ratios (LR+/LR-) were used to calculate the diagnostic OR (DOR) to assess the diagnostic performance. RESULTS: After application of exclusion criteria, 526 patients (379 axSpA (136 women and 243 men) and 147 controls with chronic low back pain) were included. No major sex-specific differences in the diagnostic performance were shown for bone marrow oedema (DOR m: 3.0; f: 3.9). Fat metaplasia showed a better diagnostic performance in men (DOR 37.9) than in women (DOR 5.0). Lower specificity was seen in women for erosions (77% vs 87%), sclerosis (44% vs 66%), fat metaplasia (87% vs 96%). CONCLUSION: The diagnostic performance of structural MRI markers is substantially lower in female patients with axSpA; active inflammatory lesions show comparable performance in both sexes, while still overall inferior to structural markers. This leads to a comparably higher risk of false positive findings in women.

HLA-B27 status and inflammatory MRI lesions of the sacroiliac joints: a post hoc analysis in patients without axial spondyloarthritis.

OBJECTIVE: The assessment of inflammatory and structural lesions in the sacroiliac joint (SIJ) is crucial in axial spondyloarthritis (axSpA). HLA-B27 status plays an important role in axSpA diagnosis and has been linked to MRI lesion burden in the general population. We aimed to investigate the sex-specific influence of HLA-B27 status on inflammatory and structural MRI findings in patients with low back pain of non-inflammatory origin. METHODS: This post hoc analysis included 139 non-axSpA patients (90 women) with chronic low back pain. Two readers scored MRIs of the SIJ for the presence of sclerosis, erosion, fat metaplasia, bone marrow oedema (BMO) and ankylosis. Frequencies and extent of lesions were compared regarding the HLA-B27 status using χ2 tests and t-tests. Regression models to assess the sex-dependent influence of HLA-B27 on lesion burden were computed. RESULTS: HLA-B27 was positive in 33 women (36.7%) and 23 men (46.9%). The overall occurrence of all SIJ lesions did not differ in HLA-B27 negative and positive individuals. There were no significant differences in the extent of lesions considering the HLA-B27 positivity, for erosion (mean sum score (MSS) of 0.91 vs 0.48; p=0.144), sclerosis (MSS 1.65 vs 1.88; p=0.576), fat metaplasia (MSS 0.56 vs 0.27; p=0.425), BMO (MSS 0.75 vs 0.59; p=0.460) and ankylosis (MSS 0.06 vs 0.04; p=0.659). CONCLUSION: HLA-B27 status has no significant influence on the occurrence and extent of SIJ lesions in patients with low back pain of non-inflammatory origin in either men or women.

Four-dimensional computed tomography detects dynamic three-dimensional pathologies of the wrist in patients with calcium pyrophosphate deposition disease.

Objectives: Crystal deposits in ligaments of the wrist are typical findings in patients with calcium pyrophosphate deposition (CPPD) disease. CPPD crystals trigger inflammation and ultimately result in ligament tears with scapholunate (SL) advanced collapse (SLAC). This study aimed to investigate carpal instabilities in patients with CPPD using four-dimensional computed tomography (4D-CT) of the wrist. Methods: This IRB-approved prospective feasibility study investigated patients with CPPD of the hand. All patients underwent a static 3D-CT and two dynamic 4D-CT in ulnar- and radial abduction and in supination and pronation movements to analyze instabilities of the SL region and of the distal radioulnar joint (DRUJ). Two independent readers scored the images for the presence of SL ligament and triangular fibrocartilage complex (TFCC) calcifications. Furthermore, the readers assessed the dynamic images for SL and DRUJ instabilities. Descriptive analyses were performed. Inter-rater reliability was assessed using Cohen's kappa (κ). Results: Nine patients were included. SL ligament calcifications and instabilities were found in all patients. Of these, dynamic SL instability was detected in 77.8% of the patients, while 22.2% had a SLAC wrist. TFCC calcifications were found in 87.5% of the patients. Four patients had DRUJ instability (50%). No patient showed DRUJ instability without the presence of TFCC calcifications. Agreement between readers for calcifications was excellent (κ = 1) and almost perfect (κ = 0.89) for instabilities. Conclusion: This study provides the first evidence of relevant dynamic carpal instability in CPPD patients using advanced imaging techniques with 4D-CT, offering unique insights into wrist biomechanics.

Influence of contrast medium on tophus detection using dual-energy CT: phantom study and clinical illustration.

BACKGROUND: To investigate the influence of iodinated contrast medium (ICM) on detection of monosodium urate (MSU) with dual-energy computed tomography (DECT) in two types of phantoms and demonstrate an example patient for clinical illustration. METHODS: Approval is by the institutional review board, and written informed consent was obtained. A grid-like and a biophantom with 25 suspensions containing different concentrations of ICM (0 to 2%) and MSU (0 to 50%) were prepared and scanned with sequential single-source DECT using established methodology. Ascending orders of tube currents were applied at 80 kVp (16.5 to 220.0 mAs) and 135 kVp (2.75 to 19.25 mAs). Volume and mass measurements were performed using clinical gout software (dual-energy decomposition analysis). Numbers of true-positive and false-positive MSU detections were recorded and compared for different ICM concentrations. We demonstrate a patient with gouty arthritis for clinical illustration. RESULTS: Effects of ICM on MSU detection varied with the amount of iodine. Lower ICM concentrations (0.25 and 0.50%) improved detection of small uric acid concentrations of 35 to 45% in comparison to scans without ICM. However, high ICM concentrations (1 and 2%) almost completely precluded MSU detection for all MSU concentrations investigated. In a patient with gouty arthritis, tophi in the wrist were only detected after intravenous ICM administration. CONCLUSIONS: Exploring multimodal DECT for arthritis imaging, enhancement of ICM influences tophus detection. It can help in visualizing previously undetected MSU depositions but, with too strong enhancement, also obscure tophi. RELEVANCE STATEMENT: Use of iodinated contrast media in dual-energy CT might help in visualizing previously undetected uric acid depositions but, with too strong enhancement, obscure gouty tophi. KEY POINTS: • Iodine significantly influences the uric acid crystal detection in systematic phantom studies. • Lower iodine concentrations improved detection of low and medium uric acid concentrations. • High concentrations of iodine hampered detection of all uric acid concentrations.

Clustered Occurrence of Osteitis Condensans Ilii in Patients with Symptomatic Hip Dysplasia.

BACKGROUND: Osteitis condensans ilii (OCI) is a relatively rare benign disease of the lower anterior sacroiliac joint (SIJ) region that can cause symptoms such as low back pain (LBP), lateral hip pain and nonspecific hip or thigh pain. Its exact pathoetiology remains to be clarified. The aim of this study is to determine the prevalence of OCI in patients with symptomatic developmental dysplasia of the hip (DDH) undergoing periacetabular osteotomy (PAO) to identify potential clustering of OCI in a with altered biomechanics of hip and SIJs. METHODS: A retrospective investigation of all patients who underwent periacetabular osteotomy in a tertiary reference hospital from January 2015 to December 2020. Clinical and demographic data were retrieved from the hospital's internal medical records. Radiographs and magnetic resonance images (MRIs) were reviewed for the presence of OCI. A t-test for independent variables was conducted to identify differences between patients with and without OCI. A binary logistic regression model was established to determine the influence of age, sex and body mass index (BMI) on the presence of OCI. RESULTS: The final analysis included 306 patients (81% female). In 21.2% of the patients (f: 22.6%; m: 15.5%), OCI was present. BMI was significantly higher in patients with OCI (23.7 kg/m2 vs. 25.0 kg/m2; p = 0.044). Binary logistic regression revealed that a higher BMI increased the likelihood of sclerosis in typical osteitis condensans locations, OR = 1.104 (95%-CI [1.024, 1.191]), as did female sex, OR = 2.832 (95%-CI [1.091, 7.352]. CONCLUSIONS: Our study revealed a considerably higher prevalence of OCI in patients with DDH than in the general population. Furthermore, BMI was shown to have an influence on the occurrence of OCI. These results support the theory that OCI is attributable to altered mechanical loading of the SIJs. Clinicians should be aware that OCI is common in patients with DDH and a potential cause of LBP, lateral hip pain and nonspecific hip or thigh pain.

New bone formation at the sacroiliac joint in axial spondyloarthritis: characterization of backfill in MRI and CT.

OBJECTIVE: MRI findings of the SI joint space in axial SpA (axSpA) include inflammation and fat metaplasia inside an erosion; the latter is also termed 'backfill'. We compared such lesions with CT to better characterize whether they represent new bone formation. METHODS: We identified patients with axSpA who underwent both CT and MRI of the SI joints in two prospective studies. MRI datasets were jointly screened by three readers for joint space-related findings and grouped into three categories: type A-high short tau inversion recovery (STIR) and low T1 signal; type B-high signal in both sequences; type C-low STIR and high T1 signal. Image fusion was used to identify MRI lesions in CT before we measured Hounsfield units (HU) in each lesion and surrounding cartilage and bone. RESULTS: Ninety-seven patients with axSpA were identified and we included 48 type A, 88 type B, and 84 type C lesions (maximum 1 lesion per type and joint). The HU values were 73.6 (s.d. 15.0) for cartilage, 188.0 (s.d. 69.9) for spongious bone, 1086.0 (s.d. 100.3) for cortical bone, 341.2 (s.d. 96.7) for type A, 359.3 (s.d. 153.5) for type B and 446.8 (s.d. 123.0) for type C lesions. Lesion HU values were significantly higher than those for cartilage and spongious bone, but lower than those for cortical bone (P < 0.001). Type A and B lesions showed similar HU values (P = 0.93), whereas type C lesions were denser (P < 0.001). CONCLUSION: All joint space lesions show increased density and might contain calcified matrix, suggesting new bone formation, with a gradual increase in the proportion of calcified matrix towards type C lesions (backfill).

Sex Disparities of the Sacroiliac Joint: Focus on Joint Anatomy and Imaging Appearance.

The sacroiliac joint (SIJ) is an anatomically complex joint which, as a functional unit with the pelvis and spine, is of decisive biomechanical importance for the human body. It is also a commonly overlooked source of lower back pain. Like the entire bony pelvis, the SIJ exhibits major sexual dimorphisms; thus, the sex-dependent evaluation of this joint is becoming increasingly important in clinical practice, both anatomically with joint shape variations and biomechanical differences as well as in terms of image appearance. The influence of the SIJ shape, which differs in women and men, is crucial for the different biomechanical joint properties. These differences are important in the development of joint diseases at the SIJ, which shows a specific difference between the sexes. This article aims to provide an overview of sex disparities of the SIJ regarding different anatomical and imaging appearances to further understand the insights into the interplay of sex differences and SIJ disease.

Dual-Energy-CT for Osteitis and Fat Lesions in Axial Spondyloarthritis: How Feasible Is Low-Dose Scanning?

BACKGROUND: To assess the ability of low-dose dual-energy computed tomography (ld-DECT) virtual non-calcium (VNCa) images for detecting bone marrow pathologies of the sacroiliac joints (SIJs) in patients with axial spondyloarthritis (axSpA). Material and Methods: Sixty-eight patients with suspected or proven axSpA underwent ld-DECT and MRI of the SIJ. VNCa images were reconstructed from DECT data and scored for the presence of osteitis and fatty bone marrow deposition by two readers with different experience (beginner and expert). Diagnostic accuracy and correlation (Kohen's k) with magnetic resonance imaging (MRI) as the reference standard were calculated for the overall and for each reader separately. Furthermore, quantitative analysis was performed using region-of-interest (ROI) analysis. Results: Twenty-eight patients were classified as positive for osteitis, 31 for fatty bone marrow deposition. DECT's sensitivity (SE) and specificity (SP) were 73.3% and 44.4% for osteitis and 75% and 67.3% for fatty bone lesions, respectively. The expert reader achieved higher diagnostic accuracy for both osteitis (SE 93.33%; SP: 51.85%) and fatty bone marrow deposition (SE: 65%; SP: 77.55%) than the beginner (SE: 26.67%; SP: 70.37% for osteitis; SE: 60%; SP: 44.9% for fatty bone marrow deposition). Overall correlation with MRI was moderate (r = 0.25, p = 0.04) for osteitis and fatty bone marrow deposition (r = 0.25, p = 0.04). Fatty bone marrow attenuation in VNCa images (mean: -129.58 HU; ±103.61 HU) differed from normal bone marrow (mean: 118.84 HU, ±99.91 HU; p < 0.01) and from osteitis (mean: 172 HU, ±81.02 HU; p < 0.01) while osteitis did not differ significantly from normal bone marrow (p = 0.27). Conclusion: In our study, low-dose DECT failed to detect osteitis or fatty lesions in patients with suspected axSpA. Thus, we conclude that higher radiation might be needed for DECT-based bone marrow analysis.

SLC26A1 is a major determinant of sulfate homeostasis in humans.

Sulfate plays a pivotal role in numerous physiological processes in the human body, including bone and cartilage health. A role of the anion transporter SLC26A1 (Sat1) for sulfate reabsorption in the kidney is supported by the observation of hyposulfatemia and hypersulfaturia in Slc26a1-knockout mice. The impact of SLC26A1 on sulfate homeostasis in humans remains to be defined. By combining clinical genetics, functional expression assays, and population exome analysis, we identify SLC26A1 as a sulfate transporter in humans and experimentally validate several loss-of-function alleles. Whole-exome sequencing from a patient presenting with painful perichondritis, hyposulfatemia, and renal sulfate wasting revealed a homozygous mutation in SLC26A1, which has not been previously described to the best of our knowledge. Whole-exome data analysis of more than 5,000 individuals confirmed that rare, putatively damaging SCL26A1 variants were significantly associated with lower plasma sulfate at the population level. Functional expression assays confirmed a substantial reduction in sulfate transport for the SLC26A1 mutation of our patient, which we consider to be novel, as well as for the additional variants detected in the population study. In conclusion, combined evidence from 3 complementary approaches supports SLC26A1 activity as a major determinant of sulfate homeostasis in humans. In view of recent evidence linking sulfate homeostasis with back pain and intervertebral disc disorder, our study identifies SLC26A1 as a potential target for modulation of musculoskeletal health.

Approach-related anatomical differences in patients with lumbo-sacral transitional vertebrae undergoing lumbar fusion surgery at level L4/5.

INTRODUCTION: Lumbo-sacral transitional vertebrae (LSTV) are accompanied by changes in soft tissue anatomy. The aim of our retrospective study was to evaluate the effects of LSTV as well as the number of free lumbar vertebrae on surgical approaches of ALIF, OLIF and LLIF at level L4/5. MATERIAL AND METHODS: We assessed the CTs of 819 patients. Of these, 53 had LSTV from which 11 had six (6LV) and 9 four free lumbar vertebrae (4LV). We matched them for sex and age to a control group. RESULTS: Patients with LSTV had a higher iliac crest and vena cava bifurcation, a greater distance between the common iliac veins and an anterior translation of the psoas muscle at level L4/5. In contrast, patients with 6LV had a lower iliac crest and aortic bifurcation, no differences in vena cava bifurcation and distance between the iliac veins compared to the control group. CONCLUSIONS: For patients with LSTV and five or four free lumbar vertebrae, the LLIF approach at L4/5 may be hindered due to a high riding iliac crest as well as anterior shift of the psoas muscle. Whereas less mobilization and retraction of the iliac veins may reduce the risk of vascular injury at this segment by ALIF and OLIF. For patients with 6LV, a lower relative height of the iliac crest facilitates lateral approach during LLIF. For ALIF and OLIF, a stronger vessel retraction due to the deeper-seated vascular bifurcation is necessary during ALIF and is therefore potentially at higher risk for vascular injury.