A retrospective external validation study of the Birmingham Atypical Cartilage Tumour Imaging Protocol (BACTIP) for the management of solitary central cartilage tumours of the proximal humerus and around the knee.

OBJECTIVES: This study aimed to externally validate the Birmingham Atypical Cartilage Tumour Imaging Protocol (BACTIP) recommendations for differentiation/follow-up of central cartilage tumours (CCTs) of the proximal humerus, distal femur, and proximal tibia and to propose BACTIP adaptations if the results provide new insights. METHODS: MRIs of 123 patients (45 ± 11 years, 37 men) with an untreated CCT with MRI follow-up (n = 62) or histopathological confirmation (n = 61) were retrospectively/consecutively included and categorised following the BACTIP (2003-2020 / Ghent University Hospital/Belgium). Tumour length and endosteal scalloping differences between enchondroma, atypical cartilaginous tumour (ACT), and high-grade chondrosarcoma (CS II/III/dedifferentiated) were evaluated. ROC-curve analysis for differentiating benign from malignant CCTs and for evaluating the BACTIP was performed. RESULTS: For lesion length and endosteal scalloping, ROC-AUCs were poor and fair-excellent, respectively, for differentiating different CCT groups (0.59-0.69 versus 0.73-0.91). The diagnostic performance of endosteal scalloping and the BACTIP was higher than that of lesion length. A 1° endosteal scalloping cut-off differentiated enchondroma from ACT + high-grade chondrosarcoma with a sensitivity of 90%, reducing the potential diagnostic delay. However, the specificity was 29%, inducing overmedicalisation (excessive follow-up). ROC-AUC of the BACTIP was poor for differentiating enchondroma from ACT (ROC-AUC = 0.69; 95%CI = 0.51-0.87; p = 0.041) and fair-good for differentiation between other CCT groups (ROC-AUC = 0.72-0.81). BACTIP recommendations were incorrect/unsafe in five ACTs and one CSII, potentially inducing diagnostic delay. Eleven enchondromas received unnecessary referrals/follow-up. CONCLUSION: Although promising as a useful tool for management/follow-up of CCTs of the proximal humerus, distal femur, and proximal tibia, five ACTs and one chondrosarcoma grade II were discharged, potentially inducing diagnostic delay, which could be reduced by adapting BACTIP cut-off values. CLINICAL RELEVANCE STATEMENT: Mostly, Birmingham Atypical Cartilage Tumour Imaging Protocol (BACTIP) assesses central cartilage tumours of the proximal humerus and the knee correctly. Both when using the BACTIP and when adapting cut-offs, caution should be taken for the trade-off between underdiagnosis/potential diagnostic delay in chondrosarcomas and overmedicalisation in enchondromas. KEY POINTS: • This retrospective external validation confirms the Birmingham Atypical Cartilage Tumour Imaging Protocol as a useful tool for initial assessment and follow-up recommendation of central cartilage tumours in the proximal humerus and around the knee in the majority of cases. • Using only the Birmingham Atypical Cartilage Tumour Imaging Protocol, both atypical cartilaginous tumours and high-grade chondrosarcomas (grade II, grade III, and dedifferentiated chondrosarcomas) can be misdiagnosed, excluding them from specialist referral and further follow-up, thus creating a potential risk of delayed diagnosis and worse prognosis. • Adapted cut-offs to maximise detection of atypical cartilaginous tumours and high-grade chondrosarcomas, minimise underdiagnosis and reduce potential diagnostic delay in malignant tumours but increase unnecessary referral and follow-up of benign tumours.

Neuropathic-like pain in knee osteoarthritis: exploring differences in knee loading and inflammation. A cross-sectional study.

BACKGROUND: A subgroup of patients with knee osteoarthritis (OA) reports symptoms attributable to a neuropathic cause. Little to no attention has been invested on investigating differences in knee loading and inflammation in these patients. AIM: To explore differences in inflammation and knee loading in patients with knee OA categorized based on the presence of neuropathic-like pain. DESIGN: Cross-sectional study. SETTING: Ghent University Hospital, Ghent, Belgium. POPULATION: Knee OA patients. METHODS: cross-sectional analysis of data from 96 patients (mean age 64.18±7.11 years) with primary knee OA participating in a randomized controlled trial. Participants were divided into three groups (unlikely, possible and indication of neuropathic-like pain) according to the modified painDETECT questionnaire (mPDQ). Data on demographics, symptoms and physical function were obtained by questionnaires. Effusion/synovitis and bone marrow lesions (BMLs) were measured using magnetic resonance imaging. Knee loading variables (knee adduction moment [KAM], KAM impulse, and knee flexion moment [KFM]) were assessed by 3D-motion analysis. One-way analysis of covariance (ANCOVA), Chi-square test and curve analyses were used to analyze continuous, categorical and loading variables respectively. Multinomial logistic regression was used to identify predictors for neuropathic-like pain. RESULTS: Patients with indication of neuropathic-like pain exhibited higher KAM impulse compared to those with no indication of neuropathic-like pain (standard mean difference (SMD): -0.036 Nm normalized to body weight and height per second, 95% CI: -0.071, -0.001) along with greater pain intensity (SMD: 3.87 units, 95% CI: 1.90, 5.84), stiffness (SMD: 1.34 units, 95% CI: 0.19, 2.48) and worse physical function (SMD: 13.98 units 95% CI: 7.52, 20.44). Curve analysis showed no significant differences in KFM and KAM between groups. Effusion/synovitis and BMLs did not differ significantly between groups. The best predictors for indication of neuropathic-like pain were KAM impulse, Hoffa and sex. CONCLUSIONS: Knee OA patients with indication of neuropathic-like pain exhibited higher dynamic medial loading, greater pain severity and worse physical function, while inflammatory markers were not significantly different across mPDQ groups. Future longitudinal studies are warranted to strengthen the evidence and establish mechanisms to explain associations between neuropathic-like pain and knee loading. CLINICAL REHABILITATION IMPACT: Knee loading is a modifiable factor and patients with neuropathic-like pain may benefit from offloading interventions.

Diagnosis and monitoring denosumab therapy of giant cell tumors of bone: radiologic-pathologic correlation.

OBJECTIVE: To determine the value of CT and dynamic contrast-enhanced (DCE-)MRI for monitoring denosumab therapy of giant cell tumors of bone (GCTB) by correlating it to histopathology. MATERIALS AND METHODS: Patients with GCTB under denosumab treatment and monitored with CT and (DCE-)MRI (2012-2021) were retrospectively included. Imaging and (semi-)quantitative measurements were used to assess response/relapse. Tissue samples were analyzed using computerized segmentation for vascularization and number of neoplastic and giant cells. Pearson's correlation/Spearman's rank coefficient and Kruskal-Wallis tests were used to assess correlations between histopathology and radiology. RESULTS: Six patients (28 ± 8years; five men) were evaluated. On CT, good responders showed progressive re-ossification (+7.8HU/month) and cortical remodeling (woven bone). MRI showed an SI decrease relative to muscle on T1-weighted (-0.01 A.U./month) and on fat-saturated T2-weighted sequences (-0.03 A.U./month). Time-intensity-curves evolved from a type IV with high first pass, high amplitude, and steep wash-out to a slow type II. An increase in time-to-peak (+100%) and a decrease in Ktrans (-71%) were observed. This is consistent with microscopic examination, showing a decrease of giant cells (-76%), neoplastic cells (-63%), and blood vessels (-28%). There was a strong statistical significant inverse correlation between time-to-peak and microvessel density (ρ = -0.9, p = 0.01). Significantly less neoplastic (p = 0.03) and giant cells (p = 0.04) were found with a time-intensity curve type II, compared to a type IV. Two patients showed relapse after initial good response when stopping denosumab. Inverse imaging and pathological findings were observed. CONCLUSION: CT and (DCE-)MRI show a good correlation with pathology and allow adequate evaluation of response to denosumab and detection of therapy failure.

Evaluation of response to neoadjuvant chemotherapy in osteosarcoma using dynamic contrast-enhanced MRI: development and external validation of a model.

OBJECTIVE: To identify which dynamic contrast-enhanced (DCE-)MRI features best predict histological response to neoadjuvant chemotherapy in patients with an osteosarcoma. METHODS: Patients with osteosarcoma who underwent DCE-MRI before and after neoadjuvant chemotherapy prior to resection were retrospectively included at two different centers. Data from the center with the larger cohort (training cohort) was used to identify which method for region-of-interest selection (whole slab or focal area method) and which change in DCE-MRI features (time to enhancement, wash-in rate, maximum relative enhancement and area under the curve) gave the most accurate prediction of histological response. Models were created using logistic regression and cross-validated. The most accurate model was then externally validated using data from the other center (test cohort). RESULTS: Fifty-five (27 poor response) and 30 (19 poor response) patients were included in training and test cohorts, respectively. Intraclass correlation coefficient of relative DCE-MRI features ranged 0.81-0.97 with the whole slab and 0.57-0.85 with the focal area segmentation method. Poor histological response was best predicted with the whole slab segmentation method using a single feature threshold, relative wash-in rate <2.3. Mean accuracy was 0.85 (95%CI: 0.75-0.95), and area under the receiver operating characteristic curve (AUC-index) was 0.93 (95%CI: 0.86-1.00). In external validation, accuracy and AUC-index were 0.80 and 0.80. CONCLUSION: In this study, a relative wash-in rate of <2.3 determined with the whole slab segmentation method predicted histological response to neoadjuvant chemotherapy in osteosarcoma. Consistent performance was observed in an external test cohort.

Cortical Osteolytic Lesion in an Older Patient: Always Consider Metastasis.

Teaching point: Cortical metastasis has to be considered in older patients with a cortical osteolytic lesion.

Neural network algorithm for detection of erosions and ankylosis on CT of the sacroiliac joints: multicentre development and validation of diagnostic accuracy.

OBJECTIVES: To evaluate the feasibility and diagnostic accuracy of a deep learning network for detection of structural lesions of sacroiliitis on multicentre pelvic CT scans. METHODS: Pelvic CT scans of 145 patients (81 female, 121 Ghent University/24 Alberta University, 18-87 years old, mean 40 ± 13 years, 2005-2021) with a clinical suspicion of sacroiliitis were retrospectively included. After manual sacroiliac joint (SIJ) segmentation and structural lesion annotation, a U-Net for SIJ segmentation and two separate convolutional neural networks (CNN) for erosion and ankylosis detection were trained. In-training validation and tenfold validation testing (U-Net-n = 10 × 58; CNN-n = 10 × 29) on a test dataset were performed to assess performance on a slice-by-slice and patient level (dice coefficient/accuracy/sensitivity/specificity/positive and negative predictive value/ROC AUC). Patient-level optimisation was applied to increase the performance regarding predefined statistical metrics. Gradient-weighted class activation mapping (Grad-CAM++) heatmap explainability analysis highlighted image parts with statistically important regions for algorithmic decisions. RESULTS: Regarding SIJ segmentation, a dice coefficient of 0.75 was obtained in the test dataset. For slice-by-slice structural lesion detection, a sensitivity/specificity/ROC AUC of 95%/89%/0.92 and 93%/91%/0.91 were obtained in the test dataset for erosion and ankylosis detection, respectively. For patient-level lesion detection after pipeline optimisation for predefined statistical metrics, a sensitivity/specificity of 95%/85% and 82%/97% were obtained for erosion and ankylosis detection, respectively. Grad-CAM++ explainability analysis highlighted cortical edges as focus for pipeline decisions. CONCLUSIONS: An optimised deep learning pipeline, including an explainability analysis, detects structural lesions of sacroiliitis on pelvic CT scans with excellent statistical performance on a slice-by-slice and patient level. CLINICAL RELEVANCE STATEMENT: An optimised deep learning pipeline, including a robust explainability analysis, detects structural lesions of sacroiliitis on pelvic CT scans with excellent statistical metrics on a slice-by-slice and patient level. KEY POINTS: • Structural lesions of sacroiliitis can be detected automatically in pelvic CT scans. • Both automatic segmentation and disease detection yield excellent statistical outcome metrics. • The algorithm takes decisions based on cortical edges, rendering an explainable solution.

Hybrid imaging of complicating osteomyelitis in the peripheral skeleton.

Diagnosing complicating osteomyelitis (COM) is clinically challenging. Laboratory tests are of limited utility, and other than isolation of the offending organism, diagnostic imaging tests are of paramount importance. Nuclear Medicine techniques play an important role in noninvasive evaluation of osteomyelitis, using both single-photon emission tomography (SPECT) and positron emission tomography (PET) radiopharmaceuticals. It is well-known that those conventional imaging modalities are not performing well in the distinction between soft-tissue and deep bone infection due to the lack of anatomical information. These difficulties have been overcome, to a great extent, with the introduction of in-line SPECT-CT and PET-CT systems which have revolutionized the field of diagnostic medical imaging. Hybrid imaging is especially useful in sites of suspected COM with underlying structural bone alterations. The first clinical studies with these integrated hybrid machines in the field of COM, including metallic implants imaging, are highly promising. In summary, WBC/AGA SPECT-CT and FDG-PET-CT seem to be the most accurate hybrid imaging modality for COM of the peripheral bone. However, there are still false positives, especially in aseptic tibial nonunions and/or metallic implants, as well as in the immediate postoperative setting. Furthermore, there is a lack of well-designed large multicentre prospective studies. Hopefully, in the future, the complementary use of morphological and functional hybrid imaging modalities may overcome some of the challenges faced in the assessment of COM.

Morphometric analysis of the incisura fibularis in patients with unstable high ankle sprains.

OBJECTIVE: The role of the syndesmotic ankle ligaments as extrinsic stabilizers of the distal tibiofibular joint (DTFJ) has been studied extensively in patients with high ankle sprains (HAS). However, research concerning the fibular incisura as intrinsic stabilizer of the DTFJ has been obscured by a two-dimensional assessment of a three-dimensional structure. Therefore, we aimed to compare the morphometry of the incisura fibularis between patients with HAS and a control group using three-dimensional radiographic techniques. MATERIALS AND METHODS: Fifteen patients with a mean age of 44 years (SD = 15.2) diagnosed with an unstable HAS and twenty-five control subjects with a mean age of 47.4 years (SD = 6.5) were analyzed in this retrospective comparative study. The obtained CT images were converted to three-dimensional models, and the following radiographic parameters of the incisura fibularis were determined using three-dimensional measurements: incisura width, incisura depth, incisura height, incisura angle, incisura width-depth ratio, and incisura-tibia ratio. RESULTS: The mean incisura depth (M = 4.7 mm, SD = 1.1 mm), incisura height (M = 36.1 mm, SD = 5.3 mm), and incisura angle of the control group (M = 137.2°, SD = 7.9°) differed significantly from patients with a HAS (resp., M = 3.8 mm, SD = 1.1 mm; M = 31.9 mm, SD = 3.2 mm; M = 143.2°, SD = 8.3°) (P < 0.05). The incisura width, incisura width-depth ratio, and incisura-tibia ratio demonstrated no significant difference (P > 0.05). CONCLUSION: Our three-dimensional comparative analysis has detected a shallower and shorter fibular incisura in patients with HAS. This distinct morphology could have repercussion on the intrinsic or osseous stability of the DTFJ. Future prospective radiographic assessment could determine to what extend the fibular incisura morphology contributes to syndesmotic ankle injuries caused by high ankle sprains.

Case Series: Dual-Energy CT in Extra-Articular Manifestations of Gout: Main Teaching Point: Dual-energy CT is a valuable asset in the detection of extra-articular manifestations of gout.

Extra-articular manifestations of gout are common. The Achilles tendon is a frequently affected site, and uric acid deposition may have harmful effects on tendon structure and function. Advanced imaging can aid in early diagnosis, follow-up of disease activity and therapy efficacy. This case series highlights the use of dual-energy CT as a tool in diagnosing gout and in detecting extra-articular manifestations.

Sacral Tumours on MRI: A Pictorial Essay.

Tumours of the sacrum can be primary or secondary. Since the sacrum is rich in haematopoietic bone marrow, bone metastases are the most frequent aetiologies. However, tumours can arise from all components of the sacrum and primary bone tumours should be considered in case of a solitary lesion and absence of oncologic history. As the clinical signs are usually non-specific, magnetic resonance imaging has become an indispensable tool in narrowing the differential diagnosis and determining the therapeutic approach. This pictorial essay illustrates specific features of the most common sacral tumours on magnetic resonance (MR) imaging.

Prospective Comparison of F-18 Choline PET/CT Scan Versus Axial MRI for Detecting Bone Metastasis in Biochemically Relapsed Prostate Cancer Patients.

We compared fluor-18 choline positron emission tomography/computed tomography (PET/CT) and axial skeleton magnetic resonance imaging (MRI) prospectively obtained for the detection of bone metastases in non-castrated patients with biochemically recurrent prostate cancer following primary treatment. PET/CT was performed 45 min post-injection of 3-4 MBq/kg F-18 methyl choline. MRI included T1- and fluid sensitive T2-weighted images of the spine and pelvis. Readers were initially blinded from other results and all scans underwent independent double reading. The best valuable comparator (BVC) defined the metastatic status. On the basis of the BVC, 15 out of 64 patients presented with 24 bone metastases. On a patient level, the sensitivity and specificity of MRI and PET were not significantly different. On a lesion level, the sensitivity of MRI was significantly better compared to PET, and the specificity did not differ significantly. In conclusion, axial MRI is an interesting screening tool for the detection of bone metastases because of its low probability of false negative results. However, F-18 choline PET is a valuable addition as it can overrule false positive MRI results and detect non-axial metastases.

Brachial plexus 3D reconstruction from MRI with dissection validation: a baseline study for clinical applications.

PURPOSE: The present study aimed to establish a baseline for detailed 3D brachial plexus reconstruction from magnetic resonance imaging (MRI). Concretely, the goal was to determine the individual brachial plexus anatomy with maximum detail and accuracy achievable, as yet irrespective of whether the methods used could be economically and practically applied in the clinical setting. MATERIALS AND METHODS: Six embalmed cadavers were randomly taken for MRI imaging of the brachial plexus. Detailed two-dimensional (2D) segmentation for all brachial plexus parts was done. The 2D brachial plexus segmentations were 3D reconstructed using Mimics(®) software. Then, these 3D reconstructions were anatomically validated by dissection of the cadavers. After finalising the cadaver experiments, brachial plexus MRIs were obtained in three healthy male volunteers and the same reconstruction procedure as in vitro was followed. RESULTS: A procedure was developed for brachial plexus 3D reconstruction based on MRI without the use of any contrast agent. Anatomical validation of six cadaver brachial plexus reconstructions showed high correspondence with the dissected brachial plexuses. Anatomical variations of the main branches were equally present in the 3D reconstructions generated. However, there were also some differences that related to the difference between the surface anatomy of the nerve and the internal nerve structure. In vivo, it was possible to reconstruct the complete brachial plexus in such a manner that normal-appearing BPs were derived in a reproducible way. CONCLUSIONS: This study showed that the described procedure results in accurate and reproducible brachial plexus 3D reconstructions.

Prevalence of radiographic parameters predisposing to femoroacetabular impingement in young asymptomatic Chinese and white subjects.

BACKGROUND: Osteoarthritis of the hip is five to ten times more common in white people than in Chinese people. Little is known about the true prevalence of femoroacetabular impingement or its role in the development of osteoarthritis in the Chinese population. A cross-sectional study of both white and Chinese asymptomatic individuals was conducted to compare the prevalences of radiographic features posing a risk for femoroacetabular impingement in the two groups. It was hypothesized that that there would be proportional differences in hip anatomy between the white and Asian populations. METHODS: Pelvic computed tomography scans of 201 subjects (ninety-nine white Belgians and 102 Chinese; 105 men and ninety-six women) without hip pain who were eighteen to forty years of age were assessed. The original axial images were reformatted to three-dimensional pelvic models simulating standardized radiographic views. Ten radiographic parameters predisposing to femoroacetabular impingement were measured: alpha angle, anterior offset ratio, and caput-collum-diaphyseal angle on the femoral side and crossover sign, ischial spine projection, acetabular anteversion angle, center-edge angle, acetabular angle of Sharp, Tönnis angle, and anterior acetabular head index on the acetabular side. RESULTS: The white subjects had a less spherical femoral head than the Chinese subjects (average alpha angle, 56° compared with 50°; p<0.001). The Chinese subjects had less lateral acetabular coverage than the white subjects, with average center-edge angles of 35° and 39° (p<0.001) and acetabular angles of Sharp of 38° and 36° (p<0.001), respectively. A shallower acetabular configuration was predominantly present in Chinese women. CONCLUSIONS: Significant differences in hip anatomy were demonstrated between young asymptomatic Chinese and white subjects. However, the absolute size of the observed differences appears to contrast with the reported low prevalence of femoroacetabular impingement in Chinese individuals compared with the high prevalence in white populations.

Surveillance or metastasis-directed Therapy for OligoMetastatic Prostate cancer recurrence (STOMP): study protocol for a randomized phase II trial.

BACKGROUND: Metastases-directed therapy (MDT) with surgery or stereotactic body radiotherapy (SBRT) is emerging as a new treatment option for prostate cancer (PCa) patients with a limited number of metastases (≤3) at recurrence - so called "oligometastases". One of the goals of this approach is to delay the start of palliative androgen deprivation therapy (ADT), with its negative impact on quality of life. However, the lack of a control group, selection bias and the use of adjuvant androgen deprivation therapy prevent strong conclusions from published studies.The aim of this multicenter randomized phase II trial is to assess the impact of MTD on the start of palliative ADT compared to patients undergoing active surveillance. METHODS/DESIGN: Patients with an oligometastatic recurrence, diagnosed on choline PET/CT after local treatment with curative intent, will be randomised in a 1:1 ratio between arm A: active surveillance only and arm B: MTD followed by active surveillance. Patients will be stratified according to the location of metastasis (node vs. bone metastases) and PSA doubling time (≤3 vs. > 3 months). Both surgery and SBRT are allowed as MDT. Active surveillance means 3-monthly PSA testing and re-imaging at PSA progression. The primary endpoint is ADT-free survival. ADT will be started in both arms at time of polymetastatic disease (>3 metastatic lesions), local progression or symptoms. The secondary endpoints include progression-free survival, quality of life, toxicity and prostate-cancer specific survival. DISCUSSION: This is the first randomized phase 2 trial assessing the possibility of deferring palliative ADT with MDT in oligometastatic PCa recurrence. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01558427.

In-vivo evaluation of the kinematic behavior of an artificial medial meniscus implant: A pilot study using open-MRI.

BACKGROUND: In this pilot study we wanted to evaluate the kinematics of a knee implanted with an artificial polycarbonate-urethane meniscus device, designed for medial meniscus replacement. The static kinematic behavior of the implant was compared to the natural medial meniscus of the non-operated knee. A second goal was to evaluate the motion pattern, the radial displacement and the deformation of the meniscal implant. METHODS: Three patients with a polycarbonate-urethane implant were included in this prospective study. An open-MRI was used to track the location of the implant during static weight-bearing conditions, within a range of motion of 0° to 120° knee flexion. Knee kinematics were evaluated by measuring the tibiofemoral contact points and femoral roll-back. Meniscus measurements (both natural and artificial) included anterior-posterior meniscal movement, radial displacement, and meniscal height. FINDINGS: No difference (P>0.05) was demonstrated in femoral roll-back and tibiofemoral contact points during knee flexion between the implanted and the non-operated knees. Meniscal measurements showed no significant difference in radial displacement and meniscal height (P>0.05) at all flexion angles, in both the implanted and non-operated knees. A significant difference (P ≤ 0.05) in anterior-posterior movement during flexion was observed between the two groups. INTERPRETATION: In this pilot study, the artificial polycarbonate-urethane implant, indicated for medial meniscus replacement, had no influence on femoral roll-back and tibiofemoral contact points, thus suggesting that the joint maintains its static kinematic properties after implantation. Radial displacement and meniscal height were not different, but anterior-posterior movement was slightly different between the implant and the normal meniscus.

Repeated stereotactic body radiotherapy for oligometastatic prostate cancer recurrence.

PURPOSE: To assess the outcome of prostate cancer (PCa) patients diagnosed with oligometastatic disease at recurrence and treated with stereotactic body radiotherapy (SBRT). METHODS: Non-castrate patients with up to 3 synchronous metastases (bone and/or lymph nodes) diagnosed on positron emission tomography - computed tomography, following biochemical recurrence after local curative treatment, were treated with (repeated) SBRT to a dose of 50 Gy in 10 fractions or 30 Gy in 3 fractions. Androgen deprivation therapy-free survival (ADT-FS) defined as the time interval between the first day of SBRT and the initiation of ADT was the primary endpoint. ADT was initiated if more than 3 metastases were detected during follow-up even when patients were still asymptomatic. Secondary endpoints were local control, progression free survival (PFS) and toxicity. Toxicity was scored using the Common Terminology Criteria for Adverse Events. RESULTS: With a median follow-up from time of SBRT of 2 years, we treated 50 patients with 70 metastatic lesions with a local control rate of 100%. The primary involved metastatic sites were lymph nodes (54%), bone (44%), and viscera (2%). The median PFS was 19 mo (95% CI: 13-25 mo) with 75% of recurring patients having ≤3 metastases. A 2nd and 3rd course of SBRT was delivered in 19 and 6 patients respectively. This results in a median ADT-FS of 25 months (20-30 mo). On univariate analysis, only a short PSA doubling time was a significant predictor for both PFS (HR: 0.90, 95% CI: 0.82 - 0.99) and ADT-FS (HR: 0.83; 95% CI: 0.71 - 0.97). Ten patients (20%) developed toxicity following treatment, which was classified as grade I in 7 and grade II in 3 patients. CONCLUSION: Repeated SBRT for oligometastatic prostate cancer postpones palliative androgen deprivation therapy with 2 years without grade III toxicity.

Open versus arthroscopic meniscus allograft transplantation: magnetic resonance imaging study of meniscal radial displacement.

PURPOSE: In this imaging study, the radial displacement of meniscal allograft transplants (MATs), inserted with 2 different techniques, namely open soft-tissue fixation and arthroscopic bone tunnel fixation, was compared 1 year postoperatively. METHODS: In this study, 37 patients received MATs: 16 MATs (10 lateral and 6 medial) were inserted by an open soft-tissue technique (open MATs), whereas 21 MATs (14 lateral and 7 medial) were implanted by an arthroscopic bone tunnel procedure (arthroscopic MATs). Radial displacement, in millimeters, was evaluated 1 year postoperatively on 1.5-T magnetic resonance images. The number of MATs with radial displacement larger or smaller than 3 mm was determined. To compare radial displacement of open versus arthroscopic MATs, the Mann-Whitney U test was used. RESULTS: The radial displacement of open lateral and medial MATs was significantly larger (all reported P < .02) than that of arthros-copic MATs. In all cases, both open and arthroscopic, the radial displacement of MATs was significantly larger (all reported P < .007) than that of normal menisci. Radial displacement of less than 3 mm was found in 0 of 6 patients with open medial MATs versus 6 of 7 patients with arthroscopic MATs and was found in 1 of 10 patients with open lateral MATs versus 4 of 14 patients with arthroscopic MATs. CONCLUSIONS: The radial displacement of MATs arthroscopically inserted with bone tunnel fixation is significantly less than the radial displacement of MATs inserted with open soft-tissue fixation. In addition, normal menisci displace significantly less than meniscal allografts. The clinical importance of radial displacement remains to be determined. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Two-year follow-up study on clinical and radiological outcomes of polyurethane meniscal scaffolds.

BACKGROUND: Little is known about radial displacement (RD) of polyurethane (PU) scaffolds, intended for partial meniscus defect substitution; no data are available on whether rim thickness influences RD and whether RD correlates with clinical outcome scores. HYPOTHESES: The meniscus is not extruded preoperatively, but RD occurs after scaffold implantation. A thicker rim will limit RD, and there is no correlation between RD and clinical outcome. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-six patients were implanted with a PU scaffold (8 lateral, 18 medial). Radial displacement (mm) was evaluated on magnetic resonance images preoperatively and at 3 months, 1 year, and 2 years postoperatively. At each time point, it was determined whether a correlation existed between the rim and RD. Clinical outcome was determined using a visual analog scale (VAS) for pain as well as the Lysholm knee scoring scale, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) score. RESULTS: Radial displacement of lateral scaffolds was not significantly different (P = .178) either preoperatively (mean ± SD, 3.42 ± 0.99 mm) or at 3 months (4.82 ± 0.59 mm), 1 year (4.55 ± 0.87 mm), or 2 years postoperatively (4.10 ± 0.93 mm). No correlation was observed between the rim and lateral RD at all time points. Medial scaffold RD increased significantly (P < .001) from preoperative values (2.17 ± 0.84 mm) to those at 3 months (4.25 ± 0.89 mm), 1 year (4.43 ± 1.01 mm), and 2 years postoperatively (4.41 ± 0.96 mm). A strong negative correlation between medial RD and the rim was observed at all time points. There was no significant correlation between clinical outcome scores and RD, either preoperatively or postoperatively. CONCLUSION: This study demonstrated that limited medial meniscal RD was present preoperatively but increased by 2 mm after scaffold implantation. Lateral RD was also present preoperatively but did not increase after scaffold implantation. Importantly, a strong negative correlation was found between the rim and postoperative medial RD; a thicker rim limited RD. However, in the lateral compartment, rim thickness did not correlate with RD because RD was already strongly present preoperatively. Finally, no correlations were observed between scaffold RD and clinical outcome scores, either preoperatively or postoperatively.

Successful treatment of painful irreparable partial meniscal defects with a polyurethane scaffold: two-year safety and clinical outcomes.

BACKGROUND: A novel, biodegradable, polyurethane scaffold was designed to fulfill an unmet clinical need in the treatment of patients with painful irreparable partial meniscal defects. HYPOTHESIS: The use of an acellular polyurethane scaffold for new tissue generation in irreparable partial meniscal defects provides both pain relief and improved functionality. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fifty-two patients with irreparable partial meniscal defects (34 medial and 18 lateral, 88% with 1-3 previous surgeries on the index meniscus) were implanted with a polyurethane scaffold in a prospective, single-arm, multicenter, proof-of-principle study. Safety was assessed by the rate of scaffold-related serious adverse events (SAEs) and the International Cartilage Repair Society articular cartilage scoring system comparing magnetic resonance imaging (MRI) at 24 months to MRI at baseline (1 week). Kaplan-Meier time to treatment failure distributions were performed. Clinical outcomes were measured comparing visual analog scale, International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scores at 24 months from baseline (entry into study). RESULTS: Clinically and statistically significant improvements (P < .0001) compared with baseline were reported in all clinical outcome scores (baseline/24 months): visual analog scale (45.7/20.3), International Knee Documentation Committee (45.4/70.1), KOOS symptoms (64.6/78.3), KOOS pain (57.5/78.6), KOOS activities of daily living (68.8/84.2), KOOS sports (30.5/59.0), KOOS quality of life (33.9/56.6), and Lysholm (60.1/80.7), demonstrating improvements in both pain and function. The incidence of treatment failure was 9 (17.3%) patients, of which 3 patients (8.8%) had medial meniscal defects and 6 patients (33.3%) had lateral meniscal defects. There were 9 SAEs requiring reoperation. Stable or improved International Cartilage Repair Society cartilage grades were observed in 92.5% of patients between baseline and 24 months. CONCLUSION: At 2 years after implantation, safety and clinical outcome data from this study support the use of the polyurethane scaffold for the treatment of irreparable, painful, partial meniscal defects.

Tissue ingrowth after implantation of a novel, biodegradable polyurethane scaffold for treatment of partial meniscal lesions.

BACKGROUND: A novel, biodegradable, aliphatic polyurethane scaffold was designed to fulfill an unmet clinical need in the treatment of patients with irreparable partial meniscal lesions. HYPOTHESIS: Treatment of irreparable partial meniscal lesions with an acellular polyurethane scaffold supports new tissue ingrowth. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fifty-two patients (with 34 medial and 18 lateral lesions) were recruited into a prospective, single-arm, multicenter, proof-of-principle study and treated with the polyurethane scaffold. The scaffold was implanted after partial meniscectomy using standard surgeon-preferred techniques for suturing. Tissue ingrowth was assessed at 3 months by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and at 12 months by gross examination during second-look arthroscopy, in the course of which a biopsy sample from the inner free edge of the scaffold meniscus was taken for qualitative histologic analysis. RESULTS: Tissue ingrowth at 3 months was demonstrated on DCE-MRI in 35 of 43 (81.4%) patients. All but one 12-month second-look (43 of 44 [97.7%]) showed integration of the scaffold with the native meniscus and all biopsy specimens (44) showed fully vital material, with no signs of cell death or necrosis. Three distinct layers were observed based on morphologic structure, vessel structure presence or absence, and extracellular matrix composition. CONCLUSION: The DCE-MRI demonstrated successful early tissue ingrowth into the scaffold. The biopsy findings demonstrated the biocompatibility of the scaffold and ingrowth of tissue with particular histologic characteristics suggestive of meniscus-like tissue. In conclusion, these data show for the first time consistent regeneration of tissue when using an acellular polyurethane scaffold to treat irreparable partial meniscus tissue lesions.