[Calcifying tendinitis with osseous involvement : A diagnostic challenge]. / Kalzifizierende Tendinitis mit Einbruch in den Knochen : Eine diagnostische Herausforderung.

OBJECTIVE: The goal of this article is the radiological visualization of the often very difficult pathoanatomical changes associated with calcifying tendinitis, which in rare cases may erode and ultimately invade the bone. MATERIALS AND METHODS: We investigated the diagnostic reliability of radiographs, magnetic resonance imaging (MRI) and computed tomography (CT) in 11 patients with calcifying tendinitis. Eight lesions were located in the upper (4 supraspinatus tendon, 2 deltoideus tendon, 1 pectoralis tendon, 1 biceps tendon) and 3 in the lower extremity (2 gluteus tendon, 1 adductor magnus tendon). The average age was 58 years (8 women, 3 men). CASE STUDIES AND DISCUSSION: Calcifying tendinitis is the consequence of overuse of an enthesis with consecutive necrosis and calcification. However, in rare cases, erosion of the underlying bone with bone invasion, which is associated with sudden escalation of long-term pain, is observed. The detection of the pathoanatomical changes using MRI is problematic because with this method calcifications and ossifications are only indirectly visualized and, thus, can only be interpreted with uncertainty. The method of choice is CT, which can be used to demonstrate the three key elements of calcifying tendinitis, i.e., the calcified/ossified part of the tendon in the insertion area, a defect in the cortex, and calcification in the medullary space.

[Skeletal sarcoidosis]. / Skelettsarkoidose.

OBJECTIVE: Presentation of the etiology, pathology, clinical course, radiology and differential diagnostics of skeletal sarcoidosis. PATHOANATOMICAL PRINCIPLES: Noncaseating epithelioid cell granulomas can trigger solitary, multiple or disseminated osteolysis, reactive osteosclerosis and/or granulomatous synovitis. INCIDENCE: The incidence of sarcoidosis is 10-12 per 100,000 inhabitants per year. Skeletal involvement is approximately 14 %. CLINICAL ASPECTS: Skeletal involvement occurs almost exclusively in the stage of lymph node and pulmonary manifestation. Most cases of skeletal involvement are clinically asymptomatic. In the case of synovial involvement, unspecific joint complaints (arthralgia) or less commonly arthritis can occur. Typical skin alterations can be diagnostically significant. RADIOLOGY: Punch out lesions osteolysis, coarse destruction and osteosclerosis can occur, which are best visualized with projection radiography and/or computed tomography. Pure bone marrow foci without interaction with the bone can only be detected with magnetic resonance imaging (MRI) and more recently with positron emission tomography (PET), mostly as incidental findings. There is a predeliction for the hand and trunk skeleton. DIFFERENTIAL DIAGNOSTICS: Skeletal tuberculosis, metastases, multiple myeloma, Langerhans cell histiocytosis and sarcoid-like reactions in solid tumors must be differentiated. The key factors for correct diagnosis are thorax radiography, thorax CT and dermatological manifestations.

[Ewing's sarcoma, fibrogenic tumors, giant cell tumor, hemangioma of bone : Radiology and pathology]. / Ewing-Sarkom, fibrogene Tumoren, Riesenzelltumor, Hämangiom des Skeletts : Radiologie und Pathologie.

Radiological imaging only reflects the anatomy and its pathological abnormalities. Therefore, the radiologist should be able to recognize the basic features of the pathological anatomy of bone tumors. This can only be learned working closely with a pathologist who is experienced in this field. On the other hand, the pathologist needs from the radiologist their diagnostic assessment with information on size, location, aggressiveness and the existence of a bone tumor's matrix, of the whole lesion, because he usually only receives a small part for examination in the form of a biopsy. In this article, the features and fundamentals (standards) of radiological-pathological cooperation as the mainstay for a precise diagnosis in bone tumors are outlined. The radiological appearance and the histopathological features behind it are presented for Ewing's sarcoma, fibrogenic tumors, giant cell tumor, and hemangioma of the bone.

[Tumor-like diseases of the knee joint]. / Tumorähnliche Erkrankungen im Kniegelenk.

CLINICAL/METHODICAL ISSUE: Radiological diagnostics of tumor-like lesions of the knee joint. STANDARD RADIOLOGICAL METHODS: Magnetic resonance imaging (MRI), computed tomography (CT) and X-ray imaging. PERFORMANCE: Up to now there have been no studies regarding sensitivity and specificity of the various diagnostic tools (MRI, CT, X-ray) for the visualization of soft tissue tumors of the knee. PRACTICAL RECOMMENDATIONS: The method of first choice for detecting soft tissue tumors and tumor-like lesions in the knee joint is MRI.

[Bone (marrow) edema in magnetic resonance imaging - finding or only signal? A brief look behind the mirror]. / Knochen(mark)ödem in der MRT - Befund oder nur Signal? Ein kurzer Blick hinter den Spiegel.

An ill-defined area of increased signal intensity in bone marrow seen on water-sensitive magnetic resonance (MR) sequences (e. g. T2, short TI inversion recovery STIR) is usually referred to as "bone marrow edema". It may be observed with traumatic (e.g. bone bruise), inflammatory, osteoarthritic as well as neoplastic processes. Therefore, it can be confusing if the term "bone marrow edema" is used to describe a clinicoradiologic condition or diagnosis. Addressing these imaging findings as "edema equivalent" or "edema-like increased signal intensity" helps to restrict this phenomenon to a magnetic resonance sign and to avoid using it as a radiologic diagnosis. To illustrate this three case examples with corresponding MR images are presented to point out the intention of this article.

Trevor's disease (dysplasia epiphysealis hemimelica) located at the hand: case report and review of the literature.

Trevor's disease, also known as dysplasia epiphysealis hemimelica (DEH), is a rare developmental bone dysplasia, characterized by benign osteocartilaginous overgrowth. The lesion arises from an epiphysis. Its localization may be different, and it mostly occurs unilateral. In this report, we present a 40 years old woman suffering from Trevor's disease with unusual localization at the hand. Because of significant symptoms surgical excision was chosen.

Protracted disseminated skeletal metastases from angiosarcoma of the spleen.

Angiosarcomas are high-grade vascular tumors associated with poor prognosis due to their aggressive nature. Occasional skeletal manifestations present commonly as osteolytic destruction. The 55-years-old patient presented in this case report had a disease-free 4 years interval between splenectomy after primary angiosarcoma of the spleen and an unusual skeletal metastatic pattern mimicking benign angiomatosis. Despite lacking radiographic evidence for a highly aggressive osseous process, the histopathological resemblance of the bone biopsy with the primary tumor manifestation and the fulminant course of disease after onset of disseminated osseous spread confirmed the malignant character of the vascular tumor. The case demonstrates the highly variable radiographic pattern and particular pathobiological behavior of vascular malignancies.

Sequential Combination Therapy Leading to Sustained Remission in a Patient with SAPHO Syndrome.

The SAPHO syndrome represents a variety of clinically similar disorders with the key features of hyperostotic bone lesions in combination with chronic pustular skin disease. The respective pathophysiology of bone and joint manifestations in SAPHO syndrome is still a matter of discussion. For example it does not appear to represent reactive arthritis and HLA B27 antigen, with the latter being typically present in patients with spondyloarthopathies. Treatment of SAPHO syndrome is also not well established and consists of various antiinflammatory and antirheumatic drugs. Here, we report a female patient with active SAPHO syndrome suffering from sternal swelling of unknown origin that had been known for 10 years and a 4-year-history of severe lower back pain. Remarkable were also a typical pustulous palmar erythema associated with swelling and decreased motility of both MCP-I joints. Inflammation parameters were high with an ESR 68 mm/1st hour and a CRP of 19.6 mg/l. She was initially treated with rofecoxib and doxycycline, followed by sulfasalazine with only partial clinical response. Thereafter, both articular symptoms as well as cutaneous lesions responded well to a combination therapy with methotrexate and sulfasalazine. Thus, the case illustrates nicely that methotrexate in combination with another DMARD can be successfully applied to patients with long-term active SAPHO syndrome.

[Unusual digital articular destructions after radio-synovectomy and cortisone injection therapy for Bouchard arthrosis]. / Ungewöhnliche Fingergelenkdestruktionen nach Radiosynoviorthese (RSO) und Cortisoninjektionstherapie bei Bouchard-Arthrose.

UNLABELLED: Starting in 1998, a female patient suffering from activated Bouchard arthrosis was treated with intra-articular steroid injections into digits of both hands. In September 2001, an additional therapy with erbium-169 injections into the same joints was begun. The injections were continued until March 2003. No benefit was observed. Instead, severe destruction of the involved joints with articular necroses and marked periarticular calcifications had occurred. The course of events are documented by plain film examinations. CONCLUSIONS: The indication for alternating steroid injections and radio-synovectomies in patients with activated Bouchard arthrosis has to be reconsidered. In vivo and in vitro experiments are necessary to evaluate the potential harms of this combination of therapies. A close clinical and radiological control of treatment outcome with reevaluation of the indication is necessary.

[Standardized procedure for suspected bone tumor]. / Standardisiertes Vorgehen bei Knochentumorverdacht.

Real bone tumors are rarely encountered in the daily routine of radiological practice. For a general radiologist or surgeon is therefore no need for a specialist knowledge on this field.However, he should be able to distinguish "leave-me-alone-lesions" in order to avoid unnecessary biopsies.A systematic approach towards the interpretation of osteolytic lesions in projection radiograms, e.g. according to the classification of Lodwick, is mandatory. CT and MRI are additional diagnostic tools and are indicated to clear up the true anatomy,e.g. in areas of superposition artefacts in conventional radiology (e.g. axial skeleton) and to determine the inner structure of a lesion, e.g. fatty tissue, liquid/solid. This paper highlights the advantages and disadvantages and the cost-effective use of the imaging modalities including scintigraphy in the diagnosis of bon tumors and tumor-like lesions. Guidelines for the management of bony lesions will be given in detail. The option and necessity for a specialist second opinion is emphasized.

[Radiological diagnosis in contracted elbow joint. Value of CT and MRI]. / Radiologische Diagnostik beim kontrakten Ellenbogengelenk. Wertigkeit von CT und MRT.

A contracture of the elbow joint is a challenge for diagnostic radiology. Radiographs remain the method of choice for primary diagnosis, however, diagnostic confidence can be limited if periarticular ossifications or contracture do not permit evaluation of the whole joint. In these cases, CT or MRI can be used for specific diagnostic problems. Additional multiplanar or three-dimensional reformations can be used by the orthopedic surgeon for planning the surgical procedure. MRI has a great advantage in allowing visualization of muscles, capsula-ligamentous complex and articular cartilage. The main disadvantages are duration of examination time and artifacts. CT is superior in terms of spatial resolution and visualization of bony structures. MRI and CT examinations of the elbow will increase with the number of minimal invasive surgical procedures. Protocols must therefore be optimized with attention to positioning, sequence selection and image processing. This article reviews the current standards of high resolution imaging with CT and MRI, including arthrographic techniques. The pros and cons of both methods are discussed in the setting of a contracture of the elbow joint.

SKIBO diseases: a concept to avoid bloody diagnostic procedures in ambiguous skeletal lesions.

In cases with an "atypical" radiologic pattern-osteolytic as well as osteosclerotic or mixed - the radiologist should pay attention to the patient's skin. There he will often find specific changes that are the key to a correct interpretation of the radiologic abnormalities. In such cases the synopsis is of more value in differential diagnosis than more or less unspecific histologic findings. Entities with a non-arbitrary conjunction of changes of the skin and bones we call SKIBO diseases. Some of them have a high potential for mimicking malignant bone lesions, often with the consequence of unnecessary biopsies. In this article we present the typical dermatologic and radiologic signs and symptoms of neurofibromatosis, sarcoidosis and pustulotic arteroosteitis (PAO) with special focus on such skeletal lesions that may mimic malignancy.

Digital radiography with a large-scale electronic flat-panel detector vs. screen-film radiography: observer preference in clinical skeletal diagnostics.

The imaging performance of a recently developed digital flat-panel detector system was compared with conventional screen-film imaging in an observer preference study. In total, 34 image pairs of various regions of the skeleton were obtained in 24 patients; 30 image pairs were included in the study. The conventional images were acquired with 250- and 400-speed screen-film combinations, using the standard technique of our department. Within hours, the digital images were obtained using identical exposure parameters. The digital system employed a large-area (43x43 cm) flat-panel detector based on amorphous silicon (Trixell Pixium 4600), integrated in a Bucky table. Six radiologists independently evaluated the image pairs with respect to image latitude, soft tissue rendition, rendition of the periosteal and enosteal border of cortical bone, rendition of cancellous bone and the visibility of potentially present pathological changes, using a subjective five-point scale. The digital images were rated significantly (p=0.001) better than the screen-film images with respect to soft tissue rendition and image latitude. Also the rendition of the cancellous bone and the periosteal and enosteal border of the cortical bone was rated significantly (p=0.05) better for the flat-panel detector. The visibility of pathological lesions was equivalent; only large-area sclerotic lesions (n=2) were seen superiorly on screen-film images. The new digital flat-panel detector based on amorphous silicon appears to be at least equivalent to conventional screen-film combinations for skeletal examinations, and in most respects even superior.

Melorheostosis: a review of 23 cases.

The aim of this study was to review clinical and radiological signs of melorheostosis in a large series of cases. Family history, patient history, clinical data and radiological features of 23 consecutive cases of melorheostosis were investigated. Criteria for establishing the diagnosis "melorheostosis" were defined. Sixteen patients (mean age 34 years, equal ratio between genders) had chronic pain in the affected limb(s) and/or subcutaneous fibrosis and/or various skin lesions. Number of involved bones: one bone (n = 10); two bones (n = 4); three or more bones (n = 9). Anatomic distribution: upper extremity (n = 5); lower extremity (n = 16); upper and lower extremity (n = 1); sacrum (n = 1). Radiologic pattern: osteoma-like (n = 7); classic candle wax appearance (n = 5); myositis ossificans-like (n = 1); osteopathia striata-like (n = 6); mixed pattern (n = 4). Patterns different from the appearance formerly judged to be "classic" prevail. The standard concept of disease manifestation has to be adjusted. Pathogenesis remains unclear. The classic theory claims the presence of an early embryonic infection of a sensory nerve inducing changes in the respective sclerotome, but we propose the concept of mosaicism as a better explanation for the sporadic occurrence, the asymmetric "segmental" pattern with variable extent of involvement and equal gender ratio of the disease.