MRI classification of uterosacral ligament involvement in endometriosis: the Hôtel-Dieu classification.

OBJECTIVE: This study aimed to establish the first-ever MRI classification of uterosacral ligament (USL) involvement in deep infiltrating endometriosis (DIE), based on reliable preoperative MRI features correlated with positive predictive values (PPVs) determined through histopathological analysis. METHODS: Twenty-two women underwent surgery with histopathology due to symptoms highly suggestive of endometriosis. The 22 preoperative MRIs were analysed retrospectively, blinded to histopathology, and a classification of the preoperative aspect of USLs linked to PPVs was designed. RESULTS: According to their aspects, 6 radiological types of USL were identified. The "L-category" corresponded to linear types with regular or irregular margins, including types 1, 2, 3A, and 3B. The "N-category" corresponded to haemorrhagic or nodular types, including types 4, 5A, 5B, and 6. For the L-category, PPVs ranged from 75% to 88%, depending on the USL radiological type. For the N-category, PPVs were 100% for each type. In women with endometriosis symptoms, MRI underestimated USL involvement, especially for type 1. Among the 6 uteri with lateral deviation, only one false-positive result concerning the stretched USL was induced. CONCLUSIONS: In women with endometriosis symptoms, our MRI classification identified 2 USL categories, corresponding to 2 kinds of PPV; in these symptomatic patients, a normal MRI does not rule out a DIE diagnosis. ADVANCES IN KNOWLEDGE: Our MRI classification of USL involvement in endometriosis may be used as a non-invasive staging of the disease, making it much clearer for clinicians and patients. Hence, we are able to propose a suitable diagnostic and therapeutic procedure for each radiological type.

Mobility analysis of a posterior sacrospinous fixation using a finite element model of the pelvic system.

INTRODUCTION AND HYPOTHESIS: In order to improve the knowledge POP physiopathology and POP repair, a generic biomechanical model of the female pelvic system has been developed. In the literature, no study has currently evaluated apical prolapse repair by posterior sacrospinous ligament fixation using a generic model nor a patient-specific model that personalize the management of POP and predict surgical outcomes based on the patient's pre-operative Magnetic Resonance Imaging. The aim of our study was to analyze the influence of a right and/or left sacrospinous ligament fixation and the distance between the anchorage area and the ischial spine on the pelvic organ mobility using a generic and a patient-specific Finite Element model (FEM) of the female pelvic system during posterior sacrospinous ligament fixation (SSF). METHODS: Firstly, we used a generic 3D FEM of the female pelvic system previously made by our team that allowed us to simulate the mobility of the pelvic system. To create a patient-specific 3D FEM of the female pelvic system, we used a preoperative dynamic pelvic MRI of a 68 years old woman with a symptomatic stage III apical prolapse and cystocele. With these 2 models, a SSF was simulated. A right and/or left SSF and different distances between the anchorage area and the ischial spine (1 cm, 2 cm and 3 cm.) were compared. Outcomes measures were the pelvic organ displacement using the pubococcygeal line during maximal strain: Ba point for the most posterior and inferior aspect of the bladder base, C point the cervix's or the vaginal apex and Bp point for the anterior aspect of the anorectal junction. RESULTS: Overall, pelvic organ mobility decreased regardless of surgical technique and model. According to the generic model, C point was displaced by 14.1 mm and 11.5 mm, Ba point by 12.7 mm, and 12 mm and Bp point by 10.6 mm and 9.9 mm after left and bilateral posterior SSF, respectively. C point was displaced by 15.4 mm and 11.6 mm and Ba point by 12.5 mm and 13.1mm when the suture on the sacrospinous ligament was performed at 1 cm and 3 cm from the ischial spine respectively (bilateral posterior SSF configuration). According to the patient-specific model, the displacement of Ba point could not be analyzed because of a significative and asymmetric organ displacement of the bladder. C point was displaced by 4.74 mm and 2.12 mm, and Bp point by 5.30 mm and 3.24 mm after left and bilateral posterior SSF respectively. C point was displaced by 4.80 mm and 4.85 mm and Bp point by 5.35 mm and 5.38 mm when the suture on the left sacrospinous ligament was performed at 1 cm and 3 cm from the ischial spine, respectively. CONCLUSION: According to the generic model from our study, the apex appeared to be less mobile in bilateral SSF. The anchorage area on the sacrospinous ligament seems to have little effect on the pelvic organ mobilities. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04551859.

MRI characterization of pelvic floor ligaments in nulliparous women: Technique development and morphometry within the 3D pelvic inclination correction system (3D-PICS).

PURPOSE: The aim of the MRI-study was to evaluate the visibility of the pelvic floor ligaments and to analyze the ligament morphometry in 3D space. METHODS: Twenty-two nulliparous women underwent MRI with a ligament specific protocol. MR datasets were evaluated using the 3D Pelvic Inclination Correction System (3D-PICS). The round ligament (RL), sacrospinous ligament (SSL), sacrotuberous ligament (STL), urogenital diaphragm (UGD) and uterosacral ligament (USL) were analyzed. Qualitative and quantitative analysis was performed. 3D coordinates for origin and insertion points were determined relative to the symphysis; subsequently lengths and angles were calculated. Interrater reliability was calculated to validate the point determination method. RESULTS: Moderate to good visibility was reported for the RL, the SSL, the STL and the UGD. Standard deviation of the points analyzed in the different dimensions vary from 1.5 mm to 21.3 mm. Origin and insertion points of the ligaments are found within a mean standard distance of 10.7 mm. The highest variability was seen in insertion points of RL, with a standard distance of 25.4 mm. The interrater reliability was good to very good (range of intraclass correlation coefficients (ICC) from 0.58 to 0.96), except for the UGD ventral points (ICC from 0.27 to 0.55). CONCLUSIONS: This in-vivo MRI technique development study offers first exact data describing the pelvic floor ligaments in nulliparous women in 3D-PICS. Visibility, exact 3D coordinates of the origin and insertion points, lengths, angles and interrater reliability assessed for all parameters were evaluated morphometrically.

MRI Assessment of Tendon Graft After Lateral Ankle Ligament Reconstruction: Does Ligamentization Exist?

BACKGROUND: No description exists in the literature about the normal evolution of tendon graft after a lateral ankle ligament (LAL) reconstruction. PURPOSE: To assess the magnetic resonance imaging (MRI) characteristics and the evolution of the tendon graft during different moments in the follow-up after an endoscopic reconstruction of the LAL. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This prospective study included 37 consecutive patients who underwent an endoscopic reconstruction of the LAL with an autograft using the gracilis tendon to treat chronic ankle instability (CAI) resistant to nonoperative treatment (CAI group) and 16 patients without ankle instability (control group). All patients in the CAI group underwent a postoperative assessment at 6, 12, and 24 months using the Karlsson score and MRI examination. Only patients with good and excellent results were included in the study. Graft assessment consisted of qualitative measurements and quantitative evaluations of the reconstructed anterior talofibular ligament (RATFL) and reconstructed calcaneofibular ligament (RCFL), including signal-to-noise quotient (SNQ) and contrast-to-noise quotient (CNQ) measurements in proton density-fat suppressed (PD-FS) and T1-weighted sequences. The analysis of variance test was used to compare the SNQ and the CNQ at different time points for each sequence. RESULTS: The MRI signal at 6 months was increased compared with that of the control group. Next, a significant signal decrease from 6 to 24 months was noted on PD-FS and T1-weighted images. SNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P = .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. Similarly, CNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P < .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. CONCLUSION: The present study demonstrated an evolution of the MRI characteristics, suggesting a process of graft maturation toward ligamentization. This is important for clinical practice, as it suggests an evolution in graft properties and supports the possibility of creating a viable ligament.

Clinical Outcomes after Median Arcuate Ligament Release in Patients Responsive to Celiac Plexus Block.

PURPOSE: To determine if symptom relief with celiac plexus block (CPB) is associated with favorable clinical outcomes after median arcuate ligament release (MALR) surgery. MATERIALS AND METHODS: A retrospective review was performed from January 2000 to December 2021. Fifty-seven patients (42 women, 15 men; mean age, 43 years [range, 18-84 years]) with clinical and radiographic features suggestive of median arcuate ligament syndrome (MALS) underwent computed tomography (CT)-guided percutaneous CPB for suspected MALS. Clinical outcomes of CPB and MALR surgery were correlated. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines. RESULTS: CT-guided percutaneous CPB was successfully performed in all 57 (100%) patients with suspected MALS. A cohort of 38 (67%) patients showed clinical improvement with CPB. A subset of 28 (74%) patients in this group subsequently underwent open MALR surgery; 27 (96%) responders to CPB showed favorable clinical outcomes with surgery. There was 1 (4%) CPB-related mild adverse event. There were no moderate, severe, or life-threatening adverse events. CONCLUSIONS: Patients who responded to CPB were selected to undergo surgery, and 96% of them improved after surgery.

Lax Uterosacral Ligament and Urge Urinary Incontinence: MRI Findings in Symptomatic Patients Versus Healthy Volunteers.

INTRODUCTION AND HYPOTHESIS: The objective was to explore the association between urge urinary incontinence (UUI) and lax uterosacral ligaments (USL) using MRI. METHODS: Sixty-seven female participants were recruited prospectively: 41 continent volunteers (control group) and 26 patients with UUI. Static proton density- and T2-weighted turbo spin echo sequences of MR images were used. A radiologist employed a standardized grid system to record structural observations of the USLs on sequentially numbered axial MR images and then applied a four-point grading scale to assess ligament visibility. MR images were interpreted by a radiologist and a urologist, and then validated by an expert radiologist. RESULTS: The comparison between the mean length of uterosacral ligaments in the control and UUI groups was highly statistically significant (p < 0.001). The mean length of the right USL was 38 ± 11 mm, and the left USL was 35 ± 12 mm in the UUI group. In the control group, the mean length of the USL was 22 ± 9 mm on the right side and 18 ± 9 mm on the left side, along their craniocaudal extent. The highest inter-observer agreement was on the level of origin and insertion (image numbers), whereas the lowest agreement was on the anatomical site of origin and insertion of the USL in both the control and UUI groups. CONCLUSIONS: The average length of USLs in patients with UUI is significantly longer than that in healthy continent women, indicating laxity. Our findings support the relationship between the laxity of the USL and UUI symptoms and have therapeutic implications.

Diagnostic performance of high-resolution ultrasound in the evaluation of intrinsic and extrinsic wrist ligaments after trauma.

PURPOSE: To investigate the role of ultrasound (US) in the evaluation of intrinsic and extrinsic ligaments of the wrist with magnetic resonance arthrography (MRA) as the reference standard. MATERIALS AND METHODS: This prospective study included patients referred for MRA after wrist trauma. US examination was performed just before MRA. On the dorsal and palmar sides of the wrist, the intrinsic interosseus and midcarpal, extrinsic, and collateral ligaments were evaluated. MRA was performed on a 1.5-T unit. In the first 20 patients included, ligament thickness was independently assessed using US and MRA and thickness reproducibility was calculated. Ligament integrity was evaluated in all patients. RESULTS: 38 patients (22 men, 16 women; mean age: 38 years) were included. Ligament thickness reproducibility ranged between 44% for the palmar ulnocapitate ligament and 71% for the palmar scaphotriquetral ligament. US had a sensitivity, specificity, positive and negative predictive values, and accuracy of 100% in the identification of tears of the palmar (n=8) and dorsal (n=3) bands of the scapholunate ligament and the ulnar collateral ligament (n=3). It had a sensitivity of 100%, specificity of 97%, positive predictive value of 50%, negative predictive value of 100%, and accuracy of 97% in the identification of tears of the palmar ulnolunate ligament (n=1). CONCLUSION: Compared to MRA, US showed good reproducibility in the assessment of wrist ligament thickness and similar accuracy with respect to identifying tears of the scapholunate, palmar ulnolunate, and ulnar collateral ligaments.

Celiac trunk stenosis by median arcuate ligament in orthotopic liver transplantation: a potential hidden foe to the biliary tree.

BACKGROUND: Celiac trunk compression by the median arcuate ligament (MAL) increases the risk of ischemic complications following gastrointestinal surgical procedures. Previous studies suggest increased risk of hepatic artery thrombosis (HAT) in orthotopic liver transplant (OLT) recipients. The aim of this study is to investigate the impact of untreated MAL compression (MAL-C) on biliary complications in OLT. METHODS: Contrast-enhanced imaging was used to classify celiac trunk stenosis by MAL-C. Medical records were reviewed to extract pre-transplant, transplant and post-transplant data. Patients were divided into two groups: no MAL compression (nMAL-C) and MAL-C. The primary endpoint was biliary complications. Secondary endpoints were HAT and graft survival. RESULTS: 305 OLT were performed from 2010 to 2021, of which 219 were included for analysis: 185 (84.5%) patients without and 34 (15.5%) with MAL-C. The incidence of HAT was 5.9% in both groups. Biliary complications were more common in the MAL-C group (35.3% vs. 17.8%, p = 0.035). Graft survival was decreased in patients with MAL-C (p = 0.035). CONCLUSIONS: MAL-C of the celiac trunk was associated with increased risk of biliary complications and inferior graft survival in OLT patients. These findings highlight the importance of preoperative screening and treatment of MAL in this population.

Prospective diagnostic test accuracy of transvaginal ultrasound posterior approach for uterosacral ligament and torus uterinus deep endometriosis.

OBJECTIVE: To determine the diagnostic test accuracy of transvaginal ultrasound (TVS) using a standardized technique for the diagnosis of deep endometriosis (DE) of the uterosacral ligaments (USLs) and adjacent torus uterinus (TU). METHODS: This was a prospective diagnostic test accuracy study conducted at the McMaster University Medical Center Tertiary Endometriosis Clinic, Hamilton, ON, Canada. Consecutive participants were enrolled if they successfully underwent TVS and surgery by our team from 10 August 2020 to 31 October 2021. The index test was TVS using a standardized posterior approach performed and interpreted by an expert sonologist. The reference standard included direct surgical visualization on laparoscopy by the same person who performed and interpreted the ultrasound scans. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios were calculated for the TVS posterior approach for each location using the reference standard. RESULTS: There were 54 consecutive participants included upon completion of laparoscopy and histological assessment. The prevalence of DE for the left USL, right USL and TU was 42.6%, 22.2% and 14.8%, respectively. Based on surgical visualization as the reference standard, TVS demonstrated an accuracy of 92.6% (95% CI, 82.1-97.9%), sensitivity of 82.6% (95% CI, 61.2-95.1%), specificity of 100% (95% CI, 88.8-100%), PPV of 100% and NPV of 88.6% (95% CI, 76.1-95.0%) for diagnosing DE in the left USL. For DE of the right USL, TVS demonstrated an accuracy of 94.4% (95% CI, 84.6-98.8%), sensitivity of 75.0% (95% CI, 42.8-94.5%), specificity of 100% (95% CI, 91.6-100%), PPV of 100% and NPV of 93.3% (95% CI, 84.0-97.4%). For DE of the TU, TVS demonstrated an accuracy of 100% (95% CI, 93.4-100%), sensitivity of 100% (95% CI, 63.1-100%), specificity of 100% (95% CI, 92.3-100%), PPV of 100% and NPV of 100%. CONCLUSIONS: We observed high diagnostic test accuracy of the evaluated standardized TVS technique for assessing DE of the USLs and TU. Further studies evaluating this technique should be performed, particularly with less experienced observers, before considering this technique as the standard approach. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Demonstration of transverse ligament on 3D SPACE MRI in whiplash-associated disorder and nontraumatic conditions.

PURPOSE: This study aims to delineate the three-dimensional (3D) SPACE MRI findings of the transverse ligament (TL) in whiplash-associated disorder (WAD) patients, and to compare them with those from a nontraumatic group. METHODS: A retrospective analysis was performed on cervical spine MRI scans obtained from 46 patients with WAD and 62 nontraumatic individuals. Clinical features, including the WAD grade and stage, were recorded. The TL's morphological grade and the symmetricity of the lateral atlantodental interval was assessed using axial 3D T2-SPACE images. The morphological grading was evaluated using a four-point scale: 0 = homogeneously low signal intensity with normal thickness, 1 = high signal intensity with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures. Additionally, the number of cervical levels exhibiting degeneration was documented. RESULTS: When comparing the WAD and nontraumatic groups, a significant difference was observed in the proportion of high-grade TL changes (grade 2 or 3) and the number of degenerated cervical levels. Logistic regression analysis revealed that high-grade TL changes and a lower number of degenerative levels independently predicted the presence of WAD. Within the WAD group, the subset of patients with high-grade TL changes demonstrated a significantly higher mean age than the low-grade group (grade 0 or 1). CONCLUSION: High-grade morphological changes in the TL can be detected in patients with WAD through the use of 3D SPACE sequences. Clinical relevance statement 3D SPACE MRI could serve as an instrumental tool in the assessment of TL among patients with WAD. Integrating MRI findings with patient history and symptomology could facilitate the identification of potential ligament damage, and may help treatment and follow-up planning.

A rare case of a combination of ectopic kidney and medial arcuate ligament syndrome: a case report.

BACKGROUND: Ectopic kidney and median arcuate ligament syndrome are both rare conditions. The clinical presentation and diagnosis of these conditions are not well studied. There are no reports on the combination of these two rare conditions. CASE PRESENTATION: We report a 24-year-old woman with fever, dysuria, urinary frequency and left flank pain for two days. The primary diagnoses in the clinic were left acute pyelonephritis and left hydronephrosis due to throbbing pain in the left costovertebral angle and pyuria. However, further computed tomography showed right ectopic pelvic kidney, left renal pelvis dilatation without definite ureteral lesion, good bilateral renal contrast enhancement, and compression of the celiac axis due to obstruction by the median arcuate ligament. Chronic abdominal symptoms were reported by the patient after repeat history taking. The patient's condition was fully explained and discussed with her and her family, but they refused further therapy. After the acute pyelonephritis began improving, the patient was discharged for follow-up at our outpatient clinic. CONCLUSION: We present an extremely rare case of a combination of two rare conditions: ectopic kidney and median arcuate ligament syndrome. No study to date has reported on the relationship between the two diseases. Given the rarity of the two conditions, no evidence or even a hypothesis exists to explain the possible etiology of their combination. More reports are required to enhance the understanding of these rare conditions.

A comparative study of the anatomy and MRI images of the lumbar foraminal ligaments at the L1-L5 levels.

PURPOSE: The purpose of this study was to evaluate the ability of MRI images to reveal foraminal ligaments at levels L1-L5 by comparing the results with those of anatomical studies. METHODS: Eighty lumbar foramina were studied. First, the best MRI scanning parameters were selected, and the transverse and sagittal axes of each lumbar foramina were scanned to identify and record the ligament-like structures in each lumbar foramen. Then, the cadaveric specimens were anatomically studied, and all ligament structures in the lumbar foramina were retained. The number, morphology and distribution of ligaments under anatomical and MRI scanning were observed. Histological staining of the dissected ligament structures was performed to confirm that they were ligamentous tissues. Finally, the accuracy of ligament recognition in MRI images was statistically analyzed. RESULTS: A total of 233 foraminal ligaments were identified in 80 lumbar intervertebral foramina through cadaveric anatomy. The radiating ligaments (176, 75.5%) were found to be attached from the nerve root to the surrounding osseous structures, while the transforaminal ligaments (57, 24.5%) traversed the intervertebral foramina without any connection to the nerve roots. A total of 42 transforaminal ligament signals and 100 radiating ligament signals were detected in the MRI images of the 80 intervertebral foramina. CONCLUSION: The MRI can identify the lumbar foraminal ligament, and the recognition rate of the transforaminal ligament is higher than that of the radiating ligament. This study provides a new method for the clinical diagnosis of the relationship between the lumbar foraminal ligament and radicular pain.

Optical Measurement of Ligament Strain: Opportunities and Limitations for Intraoperative Application.

A feasible and precise method to measure ligament strain during surgical interventions could significantly enhance the quality of ligament reconstructions. However, all existing scientific approaches to measure in vivo ligament strain possess at least one significant disadvantage, such as the impairment of the anatomical structure. Seeking a more advantageous method, this paper proposes defining medical and technical requirements for a non-destructive, optical measurement technique. Furthermore, we offer a comprehensive review of current optical endoscopic techniques which could potentially be suitable for in vivo ligament strain measurement, along with the most suitable optical measurement techniques. The most promising options are rated based on the defined explicit and implicit requirements. Three methods were identified as promising candidates for a precise optical measurement of the alteration of a ligaments strain: confocal chromatic imaging, shearography, and digital image correlation.

Findings consistent with equine proximal suspensory desmitis can be reliably detected using computed tomography and differ between affected horses and controls.

The objective of this retrospective, observational, controlled study was to evaluate bone and soft tissue window CT images of the proximoplantar metatarsus III region in twenty horses with pain localized to the proximal suspensory ligament (PSL) and 20 horses with findings nonrelated to tarsal pain. All horses underwent CT and radiographic examination. Images were reviewed by three independent observers who graded the severity and localization of findings. Bone-related categories as well as soft tissue-related categories were evaluated. For the comparison of imaging findings in horses with and without proximal suspensory desmitis (PSD), mixed linear regression was performed. The intraclass correlation coefficient (ICC) was calculated to assess intraobserver agreement, and kappa statistics were employed to evaluate interobserver agreement. CT examination identified significantly more abnormalities in the diseased group. The scores for osseous exostosis (p = .015) and PSL enlargement (p = .004) were notably higher in PSD horses compared to controls. Intraobserver agreement was overall high (ICC .82-1.0), and interobserver agreement was substantial for the detection of mineralization (kappa = .61) and moderate for sclerosis (kappa = .43), exostosis (kappa = .43), and PSL enlargement (kappa = .48/.51). Measurements in the soft tissue window were significantly smaller than those in the bone window. Findings concurrent with PSD including osseous proliferation and sclerosis as well as soft tissue enlargement, mineralization, and avulsion can be reliably detected using CT. Findings from the current study supported the use of CT for evaluating horses with suspected PSD where high-field MRI is not available.

Torsion of the Falciform Ligament Diagnosed by Imaging Tests - Case Report of an Unusual Disease.

The falciform ligament is a peritoneal double layer that anatomically divides the right and left hepatic lobes. Abnormality of the falciform ligament is rare - less than 20 cases of torsion of the falciform ligament have been reported to date in adults. The pathophysiology of these entities is similar to intra-abdominal focal fat infarction. The clinical of the patient with torsion of the falciform ligament is abdominal pain of sudden onset and focal location. Laboratory tests can lead to diagnostic confusion with cholecystitis. Ultrasonography is usually the initial evaluation test, but the gold standard diagnosis is computed tomography. We report the case of a 30-year-old female patient reporting sudden abdominal pain that radiates to the dorsal region associated with nausea and vomiting diagnosed with torsion of the falciform ligament with ultrasonography and confirmed with computed tomography. She was treated conservatively without the need for surgical treatment, being discharged after one week hospitalization.

Mild endometriosis of the uterosacral ligaments: a retrospective study of magnetic resonance imaging performance for diagnosis.

RESEARCH QUESTION: What are the diagnostic performances of magnetic resonance imaging (MRI) scans when used to identify mild endometriosis of the uterosacral ligaments (USL)? DESIGN: Monocentric retrospective study of patients who underwent a pelvic MRI followed by laparoscopy for determination of endometriosis between January 2016 and December 2020. Patients were included whether endometriosis of USL was suspected or not, but patients presenting large lesions that left no doubt as to their endometriotic nature on the MRI were excluded. Six criteria for the description of USL on MRI were studied to determine their diagnostic performances in predicting the presence of endometriosis on laparoscopy as follows: asymmetry, thickening, irregularity, straightness, the presence of a nodule or a hypersignal T1 spot. RESULTS: Seventy-seven patients were included. Among the criteria, 'asymmetry' and 'thickening' had the highest sensitivities (0.69 [95% confidence interval 0.54-0.80] and 0.51 [0.40-0.63], respectively) but moderate specificities (0.52 [0.31-0.73] and 0.62 [0.50-0.72]). Conversely, 'irregularity', 'nodule', 'straightness' and 'hypersignal T1 spot' were associated with high specificities (0.81 [0.70-0.89], 0.96 [0.89-0.99], 0.95 [0.87-0.99] and 0.99 [0.93-1.00], respectively) but poor sensitivities (0.22 [0.14-0.33], 0.12 [0.06-0.21], 0.08 [0.03-0.16] and 0.08 [0.03-0.16], respectively). The presence of at least one criterion for the description of the USL was associated with good sensitivity (0.80 [0.66-0.89]) but poor specificity (0.35 [0.16-0.57]). CONCLUSIONS: The results suggest that the identification of minimal changes in the normal appearance of USL should not automatically lead to a conclusion of mild endometriosis at this location.

Ultrasonographic comparison of the intermediate patellar ligament in warmbloods versus quarter horses.

Striations are present on ultrasonography of the intermediate (middle) patellar ligament in the transverse plane, which can be confused with tears. Comparison to the contralateral limb is often performed to help differentiate anatomic variation from pathologic change. The purposes of this prospective, observational study were to describe the striation patterns in Warmbloods and Quarter Horses, determine if these patterns are bilaterally symmetrical, and compare striation characteristics between Warmbloods and Quarter Horses. The intermediate patellar ligaments of six Warmblood horses and six Quarter horses, free from clinical signs of hindlimb lameness and in full work, were examined ultrasonographically. Striation pattern, striation number, and the transverse-sectional areas for intermediate patellar ligaments were compared between Warmbloods and Quarter horses. Striation patterns were also compared for the left and right limbs of each horse. A significant difference between breeds was identified at the mid-portion of the intermediate patellar ligament when both left and right ligaments were included (P = 0.02) and when comparing the right intermediate patellar ligament (P = 0.02). There were no other significant breed differences, and a parallel pattern was the most common pattern type. Two-thirds of the horses in this study had bilaterally symmetrical patterns within the distal aspect of their intermediate patellar ligaments, while one-third of the population were asymmetric. These results show that comparison of the contralateral limb during ultrasonography to determine if changes within the distal aspect of the intermediate patellar ligament are normal striations versus tears may lead to misdiagnosis in one-third of horses, regardless of breed. Other signs of pathology on ultrasonography should be used instead.

Ultrasound Characteristics and Scanning Techniques of Uterosacral Ligaments for the Diagnosis of Endometriosis: A Systematic Review.

Endometriosis is a common and painful gynaecological condition that takes an average of 6.4years to diagnose. While laparoscopic surgery is the recommend gold standard in diagnosis of endometriosis, transvaginal ultrasound (TVS) is able to assist surgeons in the planning and management of patients, especially when there is limited visualisation in the posterior compartment. Uterosacral ligaments (USL) are located in the posterior compartment and are one of the first and most common places that endometriosis deposits, The International Deep Endometriosis Analysis (IDEA) group consensus, which are the current guidelines for DE imaging, recommends a thorough ultrasound assessment to identify endometriotic disease. This includes an assessment of anatomic structures in the posterior compartment including the USLs. However, IDEA does not explicitly articulate specifics of USL imaging and measurements on ultrasound. The primary aim of this review is to determine is to identify ultrasound techniques and characteristics of USLs in the diagnosis of deep infiltrative endometriosis (DE). The secondary aim is to describe and summarise these findings into normal and pathological findings. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A population, interventions, comparator, and outcome framework was used to define a search strategy. Articles were screened using Covidence review management system, and data was extracted by two authors using a standardised and piolet-tested form. Quality assessment was conducted using the Critical Appraisal Skills Programme (CASP). Medline, Embase and Scopus and Google Scholar were searched yielding 250 articles, with 22 being included in the review. Analysis of the data demonstrated inconsistent reporting of ultrasound techniques and characteristics of USLs. Most (20/22) papers described abnormal criteria of USLs, only 5/22 papers determined what the normal USL appearance is or what techniques (11/22) were applied. Even though reporting was heterogeneous, there was a high level of tertiary centre participation with gynaecological experienced operators, therefore was a high level of agreement. Through review of the current literature, this study has investigated ultrasound techniques and characteristics of USLs for the diagnosis of DE. All papers included in this review reported presence of pathological sonographic findings of the USLs when DE was presented therefore it is recommended that USL examination become a part of TVS exams when DE is clinically suspected. This study also demonstrated that there was lack of data and no agreement when it comes to measuring USLs with DE. Even so, the current evidence demonstrates that scanning the USLs, and locating, identifying, and describing USL thickening and endometriotic nodules in the various locations using the described techniques and characteristics in this review has clinical value in early diagnosis.

Comparison between 2D TSE and 3D SPACE in the evaluation of craniocervical ligaments.

PURPOSE: To evaluate the MRI findings of the craniocervical junction ligaments and compare the 2D TSE sequence and 3D SPACE sequence on cervical spine MRI. METHODS: Eighty cervical spine MRIs were retrospectively analyzed, including 2D TSE and 3D SPACE sequences. The visibility and morphology of the transverse ligament (TL) and alar ligament (AL) were evaluated by two readers using a five-point grading scale for visibility (1 = not visible, 2 = barely visible, 3 = adequately visible, 4 = good visibility, 5 = excellent visibility) and a four-point grading scale for morphology (0 = homogeneous low SI with normal thickness, 1 = high SI with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures). The grades of the two sequences were compared. Reader agreements were measured using the percentage of exact agreement. RESULT: The visibility grade of TL was significantly higher in 3D, indicating better visualization. The morphology grade of TL was significantly lower in the 3D, indicating more normal-appearing ligament. The exact agreements of visibility and morphology grade of TL tended to be higher in 3D. On the other hand, there was no significant difference in visibility grade of AL between the two sequences. The morphological grade of AL was significantly higher in 3D. The agreement of the morphological grade of AL tended to be lower in 3D. CONCLUSION: The utilization of 3D sequences significantly improves the visibility of TL and could potentially reduce false-positive diagnoses of ligament injury.

Radiographic Thumb Metacarpal Subsidence Following Ligament Reconstruction With Tendon Interposition and Suture-Only Suspension Arthroplasty in the Treatment of Basal Joint Arthritis.

BACKGROUND: The thumb carpometacarpal (CMC) joint is a common source of osteoarthritis. Following trapeziectomy, ligament reconstruction with tendon interposition (LRTI) is considered a "gold standard" treatment, but suture-only suspension arthroplasty (SSA) has recently emerged as a simpler alternative. Currently, there is no objective radiographic study comparing subsidence following these 2 techniques. METHODS: This study is a retrospective review of 23 patients (10 LRTI, 13 SSA) that had at least 6 months of radiographic follow-up following thumb CMC arthroplasty. Posteroanterior radiographs at a preoperative timepoint, and at the 2-week and greater than 6-month postoperative timepoints were evaluated for actual trapezial height, as well as trapezial height normalized to capitate, thumb metacarpal, and proximal phalangeal heights. Normalized trapezial heights were calculated, and preoperative values were compared with greater than 6-month postoperative values. In addition, actual and normalized trapezial heights following LRTI and SSA were compared at each timepoint. RESULTS: Mean trapezial height decreased from approximately 12 to 5 mm (reduction of ~60%, P < .05) in both groups with no differences when comparing LRTI and SSA at each timepoint. All normalized trapezial heights revealed differences from preoperative to greater than 6-month postoperative timepoints, but no differences between LRTI and SSA. CONCLUSIONS: Ligament reconstruction with tendon interposition and SSA exhibit equivalent actual and normalized trapezial heights over a greater than 6-month postoperative time course.