Adaptation of the Signal Noise Quotient MRI classification for graft ligamentization analysis following ATFL and CFL anatomical reconstruction: Validation of the SNQA.

BACKGROUND: Chronic ankle instability is the most frequent clinical sign of an antero tibiofibular (ATFL) and/or calcaneo fibular ligament (CFL) tear. One common surgical technique is to use the distal tendon of the gracilis muscle to reconstruct both the ATFL and CFL. In the knee, the hamstring tendons used in anterior cruciate ligament (ACL) reconstruction may go through structural modifications called "ligamentization ". A noninvasive MRI technique has been developed using the Signal/Noise Quotient to compare the signal of the graft following reconstruction to that of the posterior cruciate ligament. To our knowledge no studies have ever evaluated radiographic changes in the graft over time. The main goal of this study was to develop a specific MRI protocol to evaluate graft remodeling following ATFL and CFL reconstruction over time. METHODS: A prospective study of the changes in the MRI signal of the ATFL-CFL graft 3-months postoperatively was performed in 20 patients. The main outcome was a comparison of the graft signal to that of the peroneal fibular tendon and the surrounding noise to determine the Ankle SNQ (SNQA). MRI images were evaluated by two senior radiologists to assess inter-rater reliability and then 2 weeks later for the intra-rater reproducibility. RESULTS: The intraclass correlation (ICC) showed excellent inter- and intra rater reliability for the ATFL SNQA (0.96 and 0.91, respectively); and for the CFL SNQA, the ICC was 0.97 and 0.99, respectively. Bland-Altman analysis showed very limited bias in the interpretation of SNQA. CONCLUSION: This preliminary study confirmed the inter- and intra- rater reliability of a new tool using the SNQA.

Risk factors for passive anterior tibial subluxation on MRI in complete ACL tear.

INTRODUCTION: In anterior cruciate ligament (ACL) tear, passive spontaneous anterior tibial subluxation (ATS), with respect to the femur, is sometimes observed on MRI. In a case-control study, ATS>3.5mm showed 100% specificity (±3.6, 95% CI) for complete ACL tear. The aim of the present study was to assess the relation between ATS on MRI and associated lesions in complete ACL tear. The study hypothesis was that associated lesions are a risk factor for ATS. MATERIAL AND METHODS: A retrospective study included patients operated on for complete ACL tear between 2010 and 2015. Exclusion criteria comprised associated posterior cruciate ligament tear, partial ACL tear, and history of knee surgery. Preoperative MRI was performed with the patient in supine position and the knee in 20° flexion in neutral rotation. ATS was measured by axial superimposition of the bicondylar slice on the slice through the tibial plateau. Associated lesions were assessed: medial and lateral menisci, collateral ligaments, posteromedial and posterolateral corners, tibiofemoral compartment cartilage and cancellous bone. Factors associated with ATS>3.5mm were analyzed. Ninety-one patients were included: mean age, 31.1±10.1 years; 34 female, 57 male. Mean time from injury to MRI was 7.8±11.7 months (range, 0.7-60 months). RESULTS: Mean ATS was 4.7±2.3mm. Inter- and intra-observer reproducibility for ATS measurement were excellent. On preoperative MRI, 61.1% of patients showed bone edema, 48.4% medial meniscal tear, and 36.3% lateral meniscal tear. ATS was significantly greater in case of medial meniscal tear (5.4±2.3mm vs. 4±2.1mm; p=0.003). No significant differences were found according to other lesions. Fifty-four patients (59.3%) showed ATS>3.5mm; risk factors comprised medial meniscal tear (OR=2.6, 95%CI [1.1-6.2]; p=0.03) and injury-to-MRI time>9 months (OR=9.8, 95% CI [1.1-85.2]; p=0.04). CONCLUSION: Spontaneous anterior tibial subluxation on MRI in complete ACL tear was significantly associated with medial meniscal tear and accident-to-MRI time. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Autologous Conditioned Plasma for tendon healing following arthroscopic rotator cuff repair. Prospective comparative assessment with magnetic resonance arthrography at 6 months' follow-up.

INTRODUCTION: Despite improvements in technique and materials for rotator cuff repair, mean re-tear rates remain close to 30%. The aim of the present study was to assess injection of Autologous Conditioned Plasma (ACP™, Arthrex) for tendon healing after arthroscopic repair. The study hypothesis was that ACP™ improves the tendon-healing rate. MATERIAL AND METHOD: A non-randomized comparative prospective study included all patients aged over 18 years operated on in 2010 for arthroscopic repair of full-thickness rotator cuff tear with≤2 fatty degeneration on the Goutallier classification, whatever the severity of retraction, on virgin non-osteoarthritic shoulder without contraindications for magnetic resonance (MR) arthrography. The surgical protocol was standardized. The first half of the patient sample received end-of-procedure ACP™ injection to the repaired tendon, tuberosity freshening surface and subacromial space, and the second (control) half received no supplementary treatment. The main endpoint was tendon healing on MR arthrography at 6 months according to Sugaya. Secondary endpoints comprised shoulder pain at rest on a numerical scale (0=no pain to 10=worst imaginable pain) and Constant functional score. RESULTS: Two of the 58 patients refused MR arthrography and 7 were lost to follow-up. Forty-nine patients (26 ACP™, 23 controls) were analyzed: 20 male, 29 female; mean age, 61±7.3 years. There were no significant intergroup differences in healing rate at 6 months (ACP™ 73.1% vs. 78.3% controls; p=0.75), shoulder pain (2±1.8 vs. 2.6±1.7, respectively; p=0.24), or Constant score (77±13.5/100 vs. 72.4±12.3, respectively; p=0.18). CONCLUSION: Associating ACP™ did not improve healing after arthroscopic rotator cuff repair. Sample size, however, had been calculated for a large expected difference, leading to lack of power. LEVEL OF EVIDENCE: III; case-control study.

A threshold value of 3.5 mm of passive anterior tibial subluxation on MRI is highly specific for complete ACL tears.

PURPOSE: To identify and quantify passive anterior tibial subluxation on MRI using a standardized measurement protocol and determine the diagnostic threshold of subluxation for complete anterior cruciate ligament tears. METHODS: A retrospective case-control study was performed. Patients who underwent surgery for a complete isolated ACL tear between 2009 and 2015 were matched for age and gender to controls with an intact ligament on knee MRI. All subjects underwent 1.5 T closed field MR imaging with the same protocol. Measurements were performed on axial sequences to evaluate translation of the medial and lateral condyles compared to the tibial plateau. Each compartment was measured between the vertical tangent to the posterior femoral condyles and the most posterior part of the tibial plateau. The main criterion was global passive subluxation measurements on MRI, corresponding to mean medial and lateral compartment subluxation. The reproducibility and diagnostic value of passive subluxation were calculated. RESULTS: Sixty (30/30) subjects were included, mean age 27.1 ± 1.7 years, 20 women and 40 men. Patients had a significantly higher global passive subluxation than controls (3.3 ± 0.6 mm vs 0.6 ± 0.2 mm, respectively p < 0.00001). Reproducibility was excellent and the diagnostic value of passive subluxation for a complete ACL tear was fair. A passive subluxation threshold of 3.5 mm had a sensitivity of 55.2%, a specificity of 100% and 77.6% of well-classified subjects. CONCLUSION: The calculated cutoff value for global passive subluxation to identify patients with a complete ACL tear was 3.5 mm, with excellent specificity and a high positive likelihood ratio. Suboptimal clinical results following ACL reconstruction could be partially due to failure to restore an anatomical femorotibial relationship. LEVEL OF EVIDENCE: III.

Arthroscopic meniscal allograft transplantation with two tibia tunnels without bone plugs: evaluation of healing on MR arthrography and functional outcomes.

INTRODUCTION: Meniscal allograft transplantation seems to be a valid therapeutic option to restore the knee function and limit the development of osteoarthritis after menisectomy. No surgical technique has been shown to provide better results than others. The main objective of this study was to assess graft healing after arthroscopic meniscal allograft transplantation without bone plugs. METHODS: This retrospective study included all patients who underwent arthroscopic meniscal allograft transplantation during 2005-2010. The meniscal horns were fixed through two tibia tunnels without bone plugs. The primary endpoint was graft healing according to Henning's criteria on MR arthrography (MRA) at 6-month follow-up. The secondary endpoints were the KOOS questionnaire, the IKDC score, measurement of the joint space and meniscal extrusion on both MRA at 6-month and MRI at last follow-up. The series included 22 patients, mean age 37 ± 7.5 years. The allograft was lateral in 20 cases and medial in 2 cases. The mean follow-up was 4.4 ± 1.6 years with one lost to follow-up. RESULTS: MR arthrography was performed in 14/21 patients at 6-months of follow-up: 8/14 (57.1%) had total graft healing, 2/14 (14.3%) partial healing and 4/14 (28.6%) no healing. At final follow-up, all functional scores had significantly improved. The average pre- and post-operative joint space thickness was similar. MRI showed meniscal extrusion in 75% of patients. CONCLUSION: The meniscal allograft transplantation without bone plugs effectively treats painful and functional sequellae of meniscectomies. The graft healed in most patients at 6-month follow-up. The long-term clinical relevance of meniscal extrusion has to be evaluated. LEVEL OF EVIDENCE: Retrospective study, Level IV.

Reliability and validity assessment of a glenoid bone loss measurement using the Bernageau profile view in chronic anterior shoulder instability.

BACKGROUND: One of the identified risk factors for anterior shoulder instability is bone loss on the anterior-inferior glenoid rim. The aim of our study was to assess intraobserver and interobserver reproducibility of the Bernageau view to estimate glenoid bone loss and validate this radiographic method with computed tomography (CT) scan. The second objective was to find correlation between Bernageau and arthroscopic bone loss measurements. MATERIALS AND METHODS: Twenty patients were included retrospectively. Two independent observers evaluated glenoid bone loss with the ratio between glenoid joint surface diameters of the pathologic and healthy shoulders on Bernageau views. Results were compared with CT (gold standard) and arthroscopic measurements. Validity and reliability of Bernageau measurement were assessed with Spearman correlation coefficients (r) and intraclass correlation coefficients (ρ). RESULTS: The interobserver and intraobserver reliability and the validity of Bernageau measurement compared with the reference test, the CT scan, were all excellent, with a Spearman ρ between 0.56 (P = .0002) and 0.95 (P < .00001) and an intraclass correlation coefficient between 0.82 (P = .0007) and 0.97 (P < .10(-5)). There was no correlation with arthroscopic evaluation. CONCLUSION: The glenoid bone defect measurement on the Bernageau profile view is a valid and reliable method. Furthermore, it is easy to use in current clinical practice. Surgeons can therefore consider it as a tool for preoperative planning, and its use could decrease CT scan indications.

Does arthroscopic rotator cuff repair actually heal? Anatomic evaluation with magnetic resonance arthrography at minimum 2 years follow-up.

PURPOSE: The goal of this series was to evaluate the clinical and anatomical outcomes of all-arthroscopic rotator cuff tears repair at a mid-term follow-up, using MR arthrography in order to assess tendon-to-bone healing. MATERIALS AND METHODS: This retrospective study included 29 patients (31 shoulders) presenting, according to Cofield classification, a small or moderate-sized supraspinatus full thickness tear with (7/31) or without (24/31) infraspinatus extension. The mean size of the tear was 2.64 ± 1.61 cm. The Constant score was used for pre- and postoperative clinical evaluation. All tendons were repaired under arthroscopic control. A single row technique was used. Biceps tenotomy and subacromial decompression were systematically performed. All patients operated arm were immobilized in a sling for 4 weeks and full activity was allowed at 6 months. At last follow-up, a rotator cuff MR arthrography was performed by an independent radiologist to evaluate the anatomical status of repair. RESULTS: The mean follow-up was 49.4 ± 17.3 months. Sixteen patients (17 shoulders) had a rotator cuff MR arthrography. Mean Constant score at last follow-up was 82.3 ± 12.4, with a mean improvement of 24%. Eighty-eight percent of repairs (15/17) showed a small or a large leakage at the MR arthrography. There was no significant correlation between the clinical and anatomical outcomes. CONCLUSION: The interest of this series is to show, at a mid-term follow-up and using an invasive imaging technique, the low rate of tendon-to-bone healing in arthroscopic rotator cuff repair but with a minimal influence on clinical outcome.

SHART: shoulder hyperabduction radiological test.

PURPOSE: To evaluate and quantify laxity of the inferior glenohumeral ligament (IGHL) in post-traumatic anterior instability of the shoulder with the shoulder hyperabduction radiological test (SHART) and correlate it with arthroscopic findings. METHODS: This prospective study included 21 patients undergoing arthroscopic stabilization for anteroinferior shoulder instability. The SHART test was performed as follows: a bilateral AP radiograph was performed in the supine position, and radiographs were compared. The shoulder was positioned in passive maximum abduction in neutral rotation, and neither general nor regional anesthesia was used. The angle between the axis of the humeral shaft and the line drawn between the lateral border of the scapular tubercle and the inferior edge of the glenoid fossa was measured. During arthroscopy, IGHL distension was classified into 4 stages according to the Detrisac classification. Extensive distension was considered to be the stages 3 and 4. RESULTS: The correlation between the SHART test and Detrisac staging was found to be statistically significant (P = 0.02). In the presence of a difference of more than 15° between the pathological and the contralateral shoulder on radiographs, the SHART test shows 87% of IGHL distension, Detrisac stages 3 and 4. CONCLUSION: We suggest that the SHART test should be added to conventional preoperative imaging tests for anterior instability.

CT and MRI of spine and sacroiliac involvement in spondyloarthropathy.

OBJECTIVE: Spondyloarthropathies are rheumatoid diseases that predominantly affect the axial skeleton, causing pain, stiffness, and ankylosis. The aims of this article are to illustrate the different stages of the diseases from early inflammatory involvement to ankylosis using CT and MRI and to discuss the role of imaging in the management of affected patients. CONCLUSION: CT and MRI are the most sensitive techniques in the detection of axial involvement, permitting earlier diagnosis and optimized treatment.

Amyloid arthropathy in the course of multiple myeloma.

OBJECTIVE: Primary amyloidosis is classical in the course of multiple myeloma (MM), but peripheral amyloid arthropathy is unusual. We evaluated the frequency and effect of amyloid arthropathy in a single center series of patients with MM. METHODS: Retrospective analysis of cases of peripheral joint amyloidosis in a cohort of patients with MM. RESULTS: Between 1978 and 1996, 11 patients (6 women, 5 men, mean age 59 yrs) were diagnosed with biopsy proven amyloid arthropathy in a cohort of 311 patients with MM. Arthritis was the first symptom of amyloidosis in all patients and occurred within the 6 months after MM diagnosis in most patients (7/11). Nine patients had light chain MM and X light chain was more common than kappa (6 vs 5). Shoulder hypertrophic arthropathy and rheumatoid arthritis-like polyarthritis were the 2 most common involved sites. In most cases, joint involvement was responsible for major limitations in activities of daily living. Amyloid deposits were clearly visible on magnetic resonance images (MRI), which also showed inflammatory synovitis in some cases. Control of MM was often associated with improvement of amyloid arthropathy, but additional rheumatological treatment--oral low dose prednisone or joint steroid injection--was often needed to achieve more complete relief. Amyloid arthropathy was not associated with decreased survival, except for patients with concomitant cardiac involvement. CONCLUSION: This series provides reliable information on amyloid arthropathy, especially regarding functional effects, anatomical lesions on MRI, and therapeutic options.