Quantifying synovitis in rheumatoid arthritis using computer-assisted manual segmentation with 3 Tesla MRI scanning.

PURPOSE: To investigate the reliability, validity and feasibility of a computer-assisted manual segmentation method for determining the synovial membrane volume as a surrogate measure for synovitis in patients with rheumatoid arthritis (RA). MATERIALS AND METHODS: The 3 Tesla (T) MRI scans were acquired in 22 early RA and 16 established RA patients. Synovial membrane volumes in postcontrast T1w axial images at three wrist joint regions were determined by two nonradiologist observers using a computer-assisted manual segmentation method. RESULTS: Intraobserver reliability, measured by intraclass correlation coefficients (ICCs), was excellent in the early (ICC = 0.99) and established (ICC = 0.99) RA cohorts. Interobserver reliability (mean ICC [95% Confidence Interval]) was moderate to excellent in the early and established RA groups (ICCs = 0.87 [0.68,0.94] and 0.88 [0.66, 0.96], respectively). There was a strong correlation between the synovial membrane volumes derived by segmentation and the RA MRI scoring system (RAMRIS) scores for synovitis at all joints in the early (Spearman rho = 0.86-0.96) and established (Spearman rho = 0.85-0.93) RA cohorts. The entire segmentation technique took 19 to 21 min per patient. CONCLUSION: Measurement of MRI synovitis using a computer-assisted manual segmentation method demonstrated excellent intraobserver and very good interobserver reliability, content validity (represented by its strong correlation with RAMRIS synovitis), and moderate feasibility.

Measuring bone erosion and edema in rheumatoid arthritis: a comparison of manual segmentation and RAMRIS methods.

PURPOSE: To investigate the reliability, feasibility, and validity of a computer-assisted manual segmentation (outlining) technique for measuring magnetic resonance imaging (MRI) bone erosion and edema at the wrist in rheumatoid arthritis (RA). MATERIALS AND METHODS: The 3T MRI scans were obtained in 22 RA patients (<2 years). Bone erosion and edema volumes were scored by two readers using outlining and were compared with RAMRIS scores. RESULTS: Using outlining, intraobserver reliability for erosions and edema was high: intraclass correlation coefficients (ICCs) = 0.994 (0.991, 0.997) and 0.996 (0.994, 0.998), respectively (Reader 1). Interobserver reliability was high for bone erosion (ICC [90% confidence interval, CI] = 0.80 [0.64, 0.92]) and comparable to RAMRIS scoring (ICC 0.78 [0.64, 0.92]), but was only moderate for bone edema (0.46 [0.00, 0.96]), compared with RAMRIS (ICC = 0.84 [0.73, 0.94]). The methods were highly correlated for erosion scores, r = 0.90, 0.82 (Readers 1 and 2) and moderately correlated for edema, r = 0.57, 0.87. CONCLUSION: Segmentation (outlining) can be used to measure the volume of MRI bone erosion and edema at the wrist in RA patients. When compared with RAMRIS scoring, outlining had similar reliability for quantifying erosions but reliability was lower for bone edema, possibly reflecting difficulty delineating the borders of affected bone.

Skin-derived tenocyte-like cells for the treatment of patellar tendinopathy.

BACKGROUND: Recent research of lateral elbow tendinopathy has led to the use of laboratory-amplified tenocyte-like cells. HYPOTHESIS: Ultrasound-guided injection of autologous skin-derived tendon-like cells are effective compared with other injectable therapies for the treatment of refractory patellar tendinosis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: From 60 patellar tendons in 46 patients with refractory patellar tendinopathy, a 4-mm skin biopsy was sampled to grow tenocyte-like collagen-producing cells. Patients were allocated into 2 groups: (1) injection with laboratory-prepared, amplified collagen-producing cells derived from dermal fibroblasts and suspended in autologous plasma from centrifuged autologous whole blood or (2) injection with autologous plasma alone. Injections were made into the sites of hypoechogenicity, intrasubstance tears, and fibrillar discontinuity within the patellar tendon. The Victorian Institute of Sport Assessment (VISA) score was used to assess pain, severity, and functional disability. Ultrasound was performed to assess structural and blood flow changes, evaluating 4 criteria: tendon thickness, hypoechogenicity, intrasubstance tears, and neovascularity. RESULTS: In the cell group, mean VISA scores improved from 44 ± 15 before treatment to 75 ± 17 at 6 months; in the plasma group, from 50 ± 18 to 70 ± 14. Estimated average difference between groups was 8.1, a significantly higher score in the cell group. Patients treated with collagen-producing cells also had significantly faster improvement and a highly significant effect of treatment, with the difference between groups estimated as 2.5 per unit increase in 1/√time. One patient treated with cell therapy had a late rupture and progressed to surgery; histopathology showed normal tendon structure. CONCLUSION: Ultrasound-guided injection of autologous skin-derived tendon-like cells can be safely used in the short term to treat patellar tendinopathy, with faster response of treatment and significantly greater improvement in pain and function than with plasma alone.

Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability.

BACKGROUND: Lateral elbow tendinopathy is a common condition often diagnosed by ultrasound. Debate exists regarding which ultrasound findings correlate with disease severity and prognosis. HYPOTHESIS: Sonographic predictors for tendon healing in patients with lateral elbow tendinopathy can be found by correlating initial ultrasound findings with subsequent changes in pain and functional disability scores after a period of nonoperative management. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Sixty-two elbows (34 right, 28 left) in 62 patients (30 male, 32 female) with a clinical diagnosis of lateral elbow tendinopathy underwent sonographic evaluation of the common extensor origin after assessment with a validated outcome measure, the Patient-Rated Tennis Elbow Evaluation (PRTEE). After 6 months of nonoperative standardized treatment (physiotherapy with eccentric loading), the PRTEE questionnaire was repeated. RESULTS: The mean pretreatment PRTEE was 78 (range, 51-97) and posttreatment score was 29 (range, 0-91). This difference in means was found to be significant (P < .0001). A positive correlation was identified between the presence of a lateral collateral ligament tear (P < .0001) and the size of the largest intrasubstance tear (P < .0001) and poor outcome. A negative correlation was identified with amount of hypoechogenicity (P = .0009). No correlation was found with age, sex, side, duration of symptoms, thickness of tendon, or amount of neovascularity. CONCLUSION: The size of intrasubstance tears and presence of a lateral collateral ligament tear on ultrasound can be used to assess lateral elbow tendinopathy severity, indicate those who may not respond to nonoperative therapy, and potentially guide more invasive treatment. Those patients with a large intrasubstance tear or tears identified on ultrasound are less likely to respond to nonoperative treatment. Presence of neovascularity has little correlation with change in pain severity or functional disability and may be a poor predictor of prognosis.

Imaging features of foot osteoid osteoma.

OBJECTIVES: We performed a retrospective review of the imaging of nine patients with a diagnosis of foot osteoid osteoma (OO). MATERIALS AND METHODS: Radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) had been performed in all patients. Radiographic features evaluated were the identification of a nidus and cortical thickening. CT features noted were nidus location (affected bone-intramedullary, intracortical, subarticular) and nidus calcification. MRI features noted were the presence of an identifiable nidus, presence and grade of bone oedema and whether a joint effusion was identified. RESULTS: Of the nine patients, three were female and six male, with a mean age of 21 years (range 11-39 years). Classical symptoms of OO (night pain, relief with aspirin) were identified in five of eight (62.5%) cases (in one case, the medical records could not be retrieved). In five patients the lesion was located in the hindfoot (four calcaneus, one talus), while four were in the mid- or forefoot (two metatarsal and two phalangeal). Radiographs were normal in all patients with hindfoot OO. CT identified the nidus in all cases (89%) except one terminal phalanx lesion, while MRI demonstrated a nidus in six of nine cases (67%). The nidus was of predominantly intermediate signal intensity on T1-weighted (T1W) sequences, with intermediate to high signal intensity on T2-weighted (T2W) sequences. High-grade bone marrow oedema, limited to the affected bone and adjacent soft tissue oedema was identified in all cases. CONCLUSIONS: In a young patient with chronic hindfoot pain and a normal radiograph, MRI features suggestive of possible OO include extensive bone marrow oedema limited to one bone, with a possible nidus demonstrated in two-thirds of cases. The presence or absence of a nidus should be confirmed with high-resolution CT.

Review: imaging of groin pain in the athlete.

Chronic groin pain is a common entity in the sporting population and causes considerable morbidity. The differential diagnosis is wide, and this article presents a review of the common causes with particular reference to anatomy, ultrasound and magnetic resonance imaging (MRI) findings.