The bright Easter bunny sign: a useful aide-memoire on MRI for costotransverse joint inflammation in axial spondyloarthritis.

AIM: To assess the significance of the "bright Easter bunny" sign on magnetic resonance imaging (MRI) to indicate inflammatory costotransverse joint (CtJ) lesions to diagnose axial spondyloarthritis (ax-SpA). MATERIALS AND METHODS: Consecutive cases of patients with ax-SpA from a specialist rheumatology clinic were analysed retrospectively over two cohorts, between 2012-2014 and 2018-2020, to determine newly diagnosed patients under the Assessment of SpondyloArthritis international Society (ASAS) criteria. Biological naive adult patients who underwent spine MRI and sacroiliac imaging with full immunological work-up and a C-reactive protein reading within 3 months of the scan were included. Blinded images were reviewed by experienced musculoskeletal radiologists. RESULT: From the 1,284 cases that were identified, 40 cases met the inclusion criteria for this study. Seven out of the 40 cases (17.5%) identified inflammatory lesions at the CtJ with five (70%) showing concordance with the bright Easter bunny sign. CONCLUSION: The bright Easter bunny sign is concordant with inflammatory costotransverse enthesitis. This aide-memoire radiological sign is often on overlooked edge-of-field sections and this emphasises the need to ensure adequate coverage of the CtJ on spine MRI protocols as an important anatomical site of inflammatory change in ax-SpA assessment.

Benign soft tissue tumours of the foot & ankle: A pictorial review.

The purpose of this pictorial review is to aid the clinician in distinguishing different benign lesions within the foot and ankle. We discuss the typical clinical and radiological findings as well as management options for intra and extra-compartmental lesions. Differentiation between sarcoma and benign lesions is imperative when presented with any mass in the foot or ankle.

Alteration of anterior cruciate ligament orientation in knees with trochlear dysplasia: description of a novel angle on MRI.

AIM: To assess changes in anterior cruciate ligament (ACL) geometry and inclination in trochlear dysplasia (TD) and analyse their significance. MATERIALS AND METHODS: Ninety-nine consecutive knees with TD and 23 normal knee magnetic resonance imaging (MRI) examinations were included as controls (n=122). Varying degrees of TD were classified into four distinct groups (A-D) according to the Dejour classification. MRI images were reviewed independently to measure four ACL angles. Interobserver and intra-observer agreements with statistical significance were determined for TD and various angles. RESULTS: A significant association was found between TD and two measured angles compared with the control group (sagittal ACL and anteromedial ACL angles, p<0.001 for each). The results indicate that TD can predispose to more vertical ACL inclination as measured in the coronal plane on MRI. No association was found with the Blumenstat angle. CONCLUSION: The present study found significant associations with TD and steeper sagittal ACL, which have been implicated in ACL failure. A novel angle (anteromedial ACL angle) is described which has significant association with TD and is specific for the anteromedial bundle as measured in the coronal plane. Careful consideration of ACL fibre orientation in the coronal plane on MRI is suggested in knees with TD and the use of this newly described angle in assessing ACL reconstruction (ACLR) grafts.

Sportsmans Groin: The Inguinal Ligament and the Lloyd Technique.

Groin pain is a catch all phrase used to define a common set of symptoms that affect many individuals. It is a common condition affecting sportsmen and women (1, 2) and is often referred to as the sportsman groin (SG). Multiple surgical operations have been developed to treat these symptoms yet no definitive imaging modalities exist to diagnose or predict prognosis. This article aims to discuss the anatomy of the groin, suggest a biomechanical pathophysiology and outline a logical surgical solution to treat the underlying pathology. A systematic clinical and imaging approach with inguinal ligament and pubic specific MRI assessment, can result in accurate selection for intervention. Close correlation with clinical examination and imaging in series is recommended to avoid misinterpretation of chronic changes in athletes.

Diagnostic triage for sarcoma: an effective model for reducing referrals to the sarcoma multidisciplinary team.

OBJECTIVE: Soft-tissue lesions are common and often benign. Owing to the rarity of soft-tissue sarcomas (STSs), evidence has shown that patients are increasingly referred urgently onto the 2-week wait pathway, which may have a detrimental impact on the management of patients with a proven STS. Imaging plays a vital role in lesion characterization and can be used to triage referrals to reduce the caseload of a sarcoma multidisciplinary team (MDT). In our institution, we established a sarcoma diagnostic triage meeting (SDTM). This study aimed to determine the effectiveness of the SDTM in reducing non-sarcomatous referrals to the main sarcoma MDT. METHODS: A retrospective review of the SDTM minutes from July 2011 to June 2012 was performed. Data collected for each case included details of referrer, referral modality and referral outcome. RESULTS: 165 cases were reviewed. 58% of referrals underwent a core biopsy or surgical excision with 85% benign pathology, the commonest being lipoma. 15% of referrals were sarcomatous lesions and were referred onwards to the main MDT. CONCLUSION: A total of 82% of the patients referred urgently with a suspicious soft-tissue mass was managed by the SDTM and hence not referred onwards to the East Midlands Sarcoma Service MDT. A diagnostic triage is effective in reducing the caseload burden of the main MDT and allowing it to be more effective. ADVANCES IN KNOWLEDGE: Referrals based on imaging can be prioritized by diagnostic triage. Diagnostic triage established in our institution reduced 82% of MDT referrals allowing a more focused MDT discussion on patients with a proven sarcoma.

Correlation between trochlear dysplasia and the notch index.

PURPOSE: To evaluate the correlation between trochlear dysplasia and the notch index. METHODS: Magnetic resonance images (MRI) of 95 knees in 54 male and 36 female patients aged 4 to 74 (mean, 28) years were reviewed by 2 musculoskeletal radiologists. Standard MRI sequences were used. Based on the Dejour classification of trochlear dysplasia, the knees were classified into normal or types A, B, C, and D. A notch index of <0.2 was considered narrow. Normal knees and knees with trochlear dysplasia were compared. RESULTS: 60 of the 95 knees had trochlear dysplasia, of which 39 were Dejour type A, 13 were type B, 7 were type C, and one was type D. Dejour types B, C, and D were combined as non-type A. Inter-observer agreement in assessing the notch index was good (Kappa=0.6). The mean notch indices in normal knees and knees with trochlear dysplasia were comparable (0.161 vs. 0.157, p=0.18), as were in Dejour type A and non-type A knees (0.154 vs. 0.160, p=0.54) and in Dejour types A, B, C, and D knees (0.154 vs. 0.165 vs 0.153 vs. 0.2, p=0.17-0.7). The rate of ACL injuries was similar in patients with normal knees and those with type-A trochlear dysplasia. A low notch index (narrow notch) was not associated with ACL injury. CONCLUSION: The notch index and trochlear morphology are 2 independent entities. A narrow notch does not imply a shallow trochlear grove.

Correlation between trochlear dysplasia and anterior cruciate ligament injury.

PURPOSE. To evaluate the correlation between trochlear dysplasia and anterior cruciate ligament (ACL) injury METHODS. Magnetic resonance images (MRIs) of 95 knees in 54 males and 36 females aged 4 to 74 (mean, 28) years who had anterior knee pain and suspected ligamentous injury were reviewed. The MRIs were independently reviewed by 2 musculoskeletal radiologists on 2 occasions. According to the Dejour classification, trochlear dysplasia was classified into types A, B, C, and D. Intra-articular injuries/ disorders of the patients included patellofemoral osteoarthritis, chondromalacia patella, meniscal tears, and ligamentous injuries. Intra- and inter-observer variability was calculated. RESULTS. 58 of the knees had trochlear dysplasia, 38 of which were Dejour type A. The intra- and inter-observer variability was good to excellent (Kappa=0.76-1). ACL tear was the most common injury (n=13). No ACL injury occurred in patients without trochlear dysplasia. The odds of having sustained an ACL injury were 8.8 fold greater in Dejour type-A knees than in non-type-A knees (p=0.023). CONCLUSION. Dejour type-A trochlear dysplasia was associated with ACL injuries.

The MR arthrographic anatomy of the biceps labral insertion and its morphological significance with labral tears in patients with shoulder instability.

INTRODUCTION: Most of the fibres of the long head of biceps tendon attach on the superior labrum just posterior to the supraglenoid tubercle. AIM: Our hypothesis was that posteriorly attached biceps tendons predispose to posterior superior labral tears and SLAP lesions. METHODS AND MATERIALS: A prospective analysis of all MR shoulder arthrograms for shoulder instability referred from the shoulder specialist clinics, performed during a one year period were reviewed by two independent observers who were blinded to clinical history. The biceps attachment was classified into four groups according to the method described in an earlier cadaveric study into four groups; posterior-type 1, predominantly posterior-type 2, equal contributions to both anterior and posterior labrum-type 3 and predominantly anterior labral attachment-type 4. Data was analysed using Kappa statistics and Fischer's exact test. RESULTS: 48 patients (33 males and 15 females) were included in this study with a mean age of 32 years. Majority, 22 patients (46%) had a type 1 attachment of the biceps on the superior labrum. There was moderate intra-observer and good interobserver agreement with a Kappa of 0.58 and 0.63 respectively. There was a significant association between a type 2 attachment and posterior tears (p≤0.04) and also between a type 2 attachment and SLAP tears (p≤0.04). CONCLUSION: Our results suggest that variation in anatomy of biceps origin influences the type of labral tears that occur in patients with shoulder instability. The importance of these findings could influence selection of individuals in throwing sports like cricket and baseball.

Pes anserine bursitis: incidence in symptomatic knees and clinical presentation.

OBJECTIVE: To determine the prevalence and associated clinical symptoms of pes anserine bursitis in symptomatic adult knees. MATERIALS AND METHODS: A retrospective review was performed of the reports of 509 knee MRI studies obtained from July 1998 to June 2004 on 488 patients presenting to an orthopaedic clinic with knee pain suspected to be due to internal derangement. The MRI studies and case histories of all patients reported to have pes anserine bursitis were reviewed. The management of these patients was also noted. RESULTS AND CONCLUSIONS: The prevalence of pes anserine bursitis as detected on MRI is 2.5%. The commonest clinical presentation was pain along the medial joint line mimicking a medial meniscal tear. We suggest that an accurate diagnosis of pes anserine bursitis on MRI will help prevent unnecessary arthroscopy and possibly initiate early treatment of the condition. Axial imaging is important in these cases to differentiate the bursa from other medial fluid collections.

Posttraumatic cystlike defects of the scaphoid: late sign of occult microfracture and useful indicator of delayed union.

OBJECTIVE: To investigate the association between radiolucencies in the scaphoid and trauma, we studied the unenhanced radiographs and CT images of 1087 adult patients. CONCLUSION: Three (0.3%) of the 1087 patients had scaphoid radiolucencies that developed after trauma. We hypothesize that in these patients a microfracture of the scaphoid or subtle fractures are the cause of persisting clinical symptoms. Persistent loading of the scaphoid due to wrist movement can lead to unrestricted compressive forces and ischemia and to the development of a bone cyst-like pathologic change, apparent on the radiograph as a radiolucency and often misreported as a cyst. An alternate term, "cystlike defect" or "pseudocyst" of the scaphoid, is suggested. Such radiolucencies are indicators of previous microfractures or an untreated episode of trauma to the scaphoid.

Dupuytren's disease in Marfan's syndrome.

We report a case of histologically confirmed Dupuytren's disease of the hand in a young man with Marfan's syndrome.