[Impingement syndrome of the ankle]. / Impingement-Syndrom des oberen Sprunggelenks.

Impingement syndrome of the ankle is a clinical diagnosis caused posttraumatically by overuse due to repetitive mechanical loading or the presence of predisposing anatomical variants. Ankle impingement syndrome is characterized by chronic pain and limited range of movement caused by mechanical compression of bony or soft tissues within the joint compartments. Ankle impingement syndrome is classified according to the various anatomical locations around the tibiotalar joint as anterior, anterolateral, anteromedial, posterior or posteromedial. Various imaging modalities are helpful in confirming the clinical diagnosis of ankle impingement. Radiography and computed tomography are used to identify bony abnormalities and intra-articular loose bodies. Magnetic resonance imaging is the modality of choice to demonstrate pathological soft tissue changes, bone marrow edema and osteochondral lesions. Dynamic sonography can identify the anatomical structures leading to impingement during movement.

[Occipitocervical junction: Aanatomy, craniometry and pathology]. / Okzipitozervikaler Übergang: Anatomie, Kraniometrie und Pathologien.

The occipitocervical junction comprises of the occiput condyles, the atlas, and the axis. The radiological evaluation of this region is supported by craniometric measurement methods which are based on predefined anatomical landmarks. The main pathologies of the occipitocervical junction are traumatic injuries, congenital anomalies or normal variants, infections, arthropathies, and tumors. In this article, the anatomy of the occipitocervical junction as well as the most important craniometric measurement methods are explained. Moreover various pathologies and similar appearing normal variants are presented.

EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice.

A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9-9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners.

[Imaging of diabetic osteopathy]. / Bildgebung der diabetischen Osteopathie.

CLINICAL ISSUE: Diabetic bone diseases are more than just osteoporosis in patients with diabetes mellitus (DM): a relatively high bone mineral density is paired with a paradoxically high risk of fragility fractures. Diabetics exhibit low bone turnover, osteocyte dysfunction, relative hypoparathyroidism and an accumulation of advanced glycation end products in the bone matrix. Besides typical insufficiency fractures, diabetics show a high risk for peripheral fractures of the lower extremities (e.g. metatarsal fractures). The correct interdisciplinary assessment of fracture risks in patients with DM is therefore a clinical challenge. STANDARD RADIOLOGICAL METHODS: There are two state of the art imaging methods for the quantification of fracture risks: dual energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT). Radiography, multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are suitable for the detection of insufficiency fractures. METHODICAL INNOVATIONS AND PERFORMANCE: Novel research imaging techniques, such as high-resolution peripheral quantitative computed tomography (HR-pQCT) provide non-invasive insights into bone microarchitecture of the peripheral skeleton. Using MR spectroscopy, bone marrow composition can be studied. Both methods have been shown to be capable of discriminating between type 2 diabetic patients with and without prevalent fragility fractures and thus bear the potential of improving the current standard of care. Currently both methods remain limited to clinical research applications. PRACTICAL RECOMMENDATIONS: DXA and HR-pQCT are valid tools for the quantification of bone mineral density and assessment of fracture risk in patients with DM, especially if interpreted in the context of clinical risk factors. Radiography, CT and MRI are suitable for the detection of insufficiency fractures.

[Inflammatory spinal disease: Spondyloarthritis: Importance of imaging]. / Entzündliche Wirbelsäulenerkrankungen: Spondylarthritis : Zentrale Bedeutung der Bildgebung.

Conventional radiography of the pelvis and lumbar spine is the method of choice for the initial evaluation of spondyloarthritis (SpA). Sacroiliitis is classified according to the modified New York grading criteria; however, to improve the early diagnosis of SpA, magnetic resonance imaging (MRI) should be performed as MRI enables the detection of early inflammation, such as subchondral bone marrow edema of the sacroiliac joints (SIJ), which defines sacroiliitis. Sacroiliitis and HLA-B27 are considered to be equivalent criteria for the diagnosis of SpA. In equivocal findings in the SIJ, an evaluation of the whole spine might be helpful because involvement of the thoracic and lumbar spine, shiny corner sign (Romanus lesions) and spondylodiscitis (Andersson lesions), as well as inflammation of the pedicles, zygoapophyseal joints and longitudinal ligaments, are typical findings in SpA. The prevalence of seronegative SpA is higher than has been previously assumed. Imaging in SpA plays an important role in selecting patients with inflammatory back pain and thus, helping to prevent irreversible changes through adequate early treatment.

[Spinal trauma: first aid from cross-sectional imaging]. / Trauma der Wirbelsäule: erste Hilfe durch Schnittbildverfahren.

The diagnosis of the traumatized spine is one of the key issues for trauma radiologists. The cross-sectional imaging procedures, computed tomography (CT) and magnetic resonance imaging (MRI) are the essential methods in spinal trauma radiology. These modalities are of great help in accurately assessing injury patterns and extent and in providing indications of patient outcome. In contrast to cross-sectional imaging, radiography has a role in the evaluation of minor spinal trauma only. It is generally accepted that trauma radiologists do not use typical classifications to evaluate the spine partly because such an ideal classification system does not yet exist. Not least because of this classification difficulty, eponyms and synonyms are widely used to describe traumatology of the spine as a high level of specific information is included in these various terms. The members of the trauma team should be aware of the strengths and limitations of the methods used in the assessment of the spine. This article provides a brief outline of fundamental knowledge about the diagnosis of spinal trauma.

The intraoperative use of ultrasound facilitates significantly the arthroscopic debridement of calcific rotator cuff tendinitis.

INTRODUCTION: During arthroscopy, the localization of calcific deposit in patients suffering from calcifying tendinitis can be demanding and time consuming, frequently using ionizing radiation. Intraoperative ultrasound has been recently promoted, facilitating deposit localization and reducing radiation dose. MATERIAL AND METHODS: In this prospective, randomized, controlled and clinical observer-blinded pilot trial, 20 patients with calcific tendinitis were operated. In group I, the deposit was localized conventionally. In group II, the deposit was localized using intraoperative ultrasound. The needle punctures to detect the deposit and operation times were noted. Patients were postoperatively evaluated after 2 and 6 weeks and 9 months. RESULTS: In group II, the needle punctures to detect the deposit were significantly lower than in group I (p < 0.0001). Operation time to localize the deposit was also significantly less in group II (p < 0.033). In both groups, patients improved significantly with increased shoulder function (p < 0.0001) and decreased pain (p < 0.0001) 2 weeks and 9 months (p < 0.001) after surgery. The difference between the groups was not significant. Excellent radiological findings were obtained in both groups after 9 months. CONCLUSIONS: Intraoperative US significantly facilitates the detection of calcific deposits during arthroscopic debridement by speeding up surgery and reducing the number of needle punctures. Hence, we have changed our method of detecting calcific deposits intraoperatively from fluoroscopy to ultrasound.

[Imaging of postarthroscopic complications after knee injuries]. / Bildgebung postarthroskopischer Komplikationen nach Knieverletzungen.

The most common joint injuries in professional and recreational sports participants and also in the total population are knee injuries. Arthroscopy is indicated if this modality will improve the patient outcome and potential long-term complications can be avoided. Although uncommon, complications following arthroscopy are mostly evaluated by magnetic resonance imaging (MRI). For planning further therapy strategies following postarthroscopic complications, e.g. if anterior cruciate ligament (ACL) reconstruction is required, digital radiographs and computed tomography (CT) are helpful. This article provides an overview of the different procedures for surgical treatment which are a prerequisite for the analysis of postarthroscopic images. In addition typical complications after treatment of meniscal and chondral injuries as well as after ACL reconstruction are described and typical signs in MRI, radiography and CT are explained in detail.

[Coxarthrosis - a radiological approach and guidelines]. / Koxarthrose - eine radiologische Annäherung und Leitfaden.

CLINICAL/METHODICAL ISSUE: Coxarthrosis is one of the most frequent indications in radiological practice with a prevalence as high as 8%. STANDARD RADIOLOGICAL METHODS: Radiography, sonography, computed tomography, magnetic resonance imaging. METHODICAL INNOVATIONS: Magnetic resonance arthrography for detection of early stages of labral and chondral pathologies as well as detection of osteonecrosis at an early stage. PERFORMANCE: Czerny C, Hofmann S, Neuhold A et al. (1996) Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology 200(1):225-230. Czerny C, Oschatz E, Neuhold A et al. (2002) [MR arthrography of the hip joint]. Radiologe 42(6):451-456. Kramer J, Breitenseher M, Imhof H et al. (2000) [Diagnostic imaging in femur head necrosis]. Orthopade 29(5):380-388. ACHIEVEMENTS: Is already established in clinical practice. PRACTICAL RECOMMENDATIONS: Each modality has relevant indications.

[Radiological imaging in early diagnosis of rheumatoid arthritis. The role of ultrasound and magnetic resonance imaging]. / Radiologische Frühdiagnostik der rheumatoiden Arthritis. Stellenwert von Ultraschall und Magnetresonanztomographie.

CLINICAL/METHODICAL ISSUE: For optimal therapy management of patients with rheumatoid arthritis (RA) specific and sensitive diagnostic methods are essential for assessment of disease activity. STANDARD RADIOLOGICAL METHODS: In addition to projection radiography, imaging techniques, in particular magnetic resonance imaging (MRI) and ultrasound (US) are becoming increasingly more important for the early diagnosis of RA. PRACTICAL RECOMMENDATIONS: The MRI and US techniques play a key role in the early imaging diagnostics of RA. Measurement of inflammation activity represents the basis of therapeutic decision-making and can be quantitatively and qualitatively determined with MRI and US. Synovitis and bone marrow edema are predictors of erosion.

[Sacroiliitis or pseudosacroiliitis?]. / Sakroiliitis oder Pseudosakroiliitis?

CLINICAL/METHODICAL ISSUE: When the presence of seronegative spondyloarthropathy is unrecognized there can be a delay in achieving an accurate diagnosis, as the typical inflammatory low back pain is similar to that found in degenerative diseases of the lumbosacral spine and the sacroiliac joints. Thus, seronegative spondyloarthropathy is often misinterpreted as a degenerative disease. The initial radiography of the sacroiliac joints is often normal which results in a delay in diagnosis of sacroiliitis of approximately 3-7 years. STANDARD RADIOLOGICAL METHODS: This illustrates the significance of an adequate imaging method for the early detection of sacroliliitis. METHODICAL INNOVATIONS: Contrast medium administration for magnetic resonance imaging (MRI) enables a differentiation between synovitis, capsulitis, enthesitis and effusion. PERFORMANCE: Sensitivity and specificity for detection of active inflammation by MRI is about 83-85%. Early active inflammation can be detected by MRI 3-7 years before structural changes are obvious by x-ray examination. PRACTICAL RECOMMENDATIONS: Pseudosacroiliitis can be differentiated from inflammatory sacroiliitis by the patient history, laboratory data, osteoproliferative and osteodestructive changes and the typical distribution pattern of bone marrow edema.

Ultrasound guidance improves the accuracy of the acromioclavicular joint infiltration: a prospective randomized study.

Degeneration of the acromioclavicular joint (AC) often causes impaired shoulder function and pain. Its infiltration results in reportedly beneficial short-term effects. Misplacement of infiltrations is observed in high numbers. A previous study showed high accuracy of infiltrations of one surgeon comparing conventional palpation technique to ultrasound guidance. This study evaluates if ultrasound-guided AC joint infiltration is feasible for therapists of different levels of experience and if the accuracy can be increased. One hundred and twenty AC joints of 60 cadavers were enrolled into a prospective, randomized observer-blinded study. Six therapists of three different levels of experience infiltrated 20 AC joints each. Half of them were infiltrated after palpation of the joint space, half of them were ultrasound-guided infiltrated. Controls were performed pre- and post-infiltration by an independent radiologist. In total, accurate infiltration was observed in 70%. In 25%, misplacement of the infiltration was recorded in the palpation-, in 2% in the ultrasound- and in 3% in both groups. The difference between the two groups was significant (P = 0.009). Ultrasound-guided infiltration to the AC joint is significantly more accurate than conventional palpation technique. This method is simple, efficient and can be applied by therapists of all levels of experience.

[Tips, tricks and pitfalls in the diagnostic imaging of traumatic spinal cord injuries]. / Tipps, tricks und fallstricke bei der bildgebung von myelonverletzungen.

Over the last several decades the survival rate for acute spinal cord lesions has improved, which has resulted in an increased number of chronic spinal cord injuries. Magnetic resonance imaging (MRI) plays an essential role in imaging of the spinal cord, as it allows a detailed depiction of neural structures. However, the correct radiologic diagnosis is often complicated by the multitude of differential diagnoses. This article provides tips and tricks to achieve an accurate imaging report and details potential pitfalls in the interpretation of MR images. Acute spinal cord injuries show different characteristics which range from edema to intramedullary bleeding and to transsection. The spectrum of chronic spinal cord injuries encompasses myelomalacia, syrinx, cystic myelopathia and myeloatrophy. In addition to typical morphological features this article concentrates on the pathogenesis of injury patterns, on the use of appropriate contrast-enhanced MR sequences and on new MR techniques for the differentiation of individual pathologies.

Intra-operative ultrasound facilitates the localization of the calcific deposit during arthroscopic treatment of calcifying tendinitis.

PURPOSE: Calcifying tendinitis is a common condition of the shoulder. In many cases, arthroscopic reduction in the deposit is indicated. The localization of the deposit is sometimes challenging and time-consuming. Pre-operative ultrasound (US)-guided needle placement in the deposit and pre-operative US marking of the deposit at the skin with a ballpoint are described and recommended methods to alleviate the procedure without using ionizing radiation by fluoroscopy. METHODS: Intra-operative sonography of the shoulder is introduced as a new method to localize the calcific deposit with high accuracy. After standard arthroscopic buresectomy, the surgeon performs an ultrasound examination under sterile conditions to localize the deposits. A ventral longitudinal US section is recommended, and the upper arm is rotated until the deposit is visible. Subsequently, perpendicular to the skin at the position of the transducer, a needle is introduced under arthroscopic and ultrasound visualization to puncture the deposit. RESULTS: The presence of snow-white crystals at the tip of the needle proves the exact localization. Consecutively, the curettage can be accomplished. Another intra-operative sonography evaluates possible calcific remnants and the tendon structure. CONCLUSION: This new technique may alleviate arthroscopic calcific deposit curettage by visualizing the deposit without using ionizing radiation. Additionally, soft tissue damage due to decreased number of punctures to detect the deposit may be achieved. Both factors may contribute to reduced operation time.

[Long-term success and risk for marathon runners]. / Langzeiterfolg und Risiko der Marathonläufer.

The popularity of marathon running has increased during recent years, which is reflected by the dramatic increase in the number of competitions and participants. Running a marathon itself does not usually cause any severe lesions of the joints but the problems mostly occur during training prior to the marathon. Before the event runners often question whether they can successfully take part in the competition and cope with the pain that might occur during running. In addition to the rare acute trauma, which is in general caused by falls or slipping, chronic injuries are of particular relevance for long distance running.This article describes the typical patterns of injuries to long distance runners, the positive effects of running a marathon and the risk factors for injuries.

The infiltration of the AC joint performed by one specialist: ultrasound versus palpation a prospective randomized pilot study.

INTRODUCTION: The acromio-clavicular (AC) joint is very susceptible to degenerative processes that result in pain and functional impairment. One common modality of treatment has been local infiltration of the joint space. Although this procedure has produced notable positive results, needle misplacement occurs frequently. The aim of this investigation is to evaluate the effects of an intra articular infiltration by comparing precise needle placement into the joint space using high-resolution-ultrasound with the conventional palpation technique. METHODS: This prospective and randomized pilot study analysed 20 patients who were assigned either to the "ultrasound" or the "palpation" group. Clinical examinations were performed before treatment and at 1h, 1 week and 3 weeks after a single infiltration of local anaesthetic and corticoid carried out by one specialist. RESULTS: In both groups significant improvement in pain and function was obtained up to one-week post injection. Function remained significantly improved until the last follow-up and did not differ between the two groups. The agent was administered in all patients into the joint space in the ultrasound group. CONCLUSION: Ultrasound guided infiltration of the AC joint is an easily achieved procedure without any complications. However, clinical follow-up did not differ between free-hand and ultrasound-guided AC joint space infiltration.