What are the predictors of clinical success after percutaneous vertebroplasty for osteoporotic vertebral fractures?

OBJECTIVES: Osteoporotic vertebral fractures are responsible for acute pain and disability that may persist for more than 2 months. We wanted to identify predicting factors for mid-term outcome after vertebroplasty. METHODS: We included consecutive patients who underwent vertebroplasty for fragility fractures with persistent and intense pain between January 2014-June 2016. Outcome was assessed by an independent clinician after 1 month using a standardized questionnaire. Patients were classified as having either a favorable or a poor outcome. Presence of an intravertebral cleft and bone oedema mean signal intensity was assessed by an independent radiologist blinded to the clinical data. Pre-intervention clinical or radiological factors were analysed as predictors for outcome. RESULTS: In the 78 included patients (females 71%, age 75 ± 8.3 years), 61.5% had a favourable outcome. When vertebroplasty was performed within 2 months after fracture, the outcome was favourable in 19 patients (39.6%) and poor in five (16.7%; estimate for favourable outcome: OR = 4.1, 95% CI 1.2-13.8, p = 0.021). Absence of intravertebral cleft on pre-intervention imaging was also a predictor of favourable outcome (OR = 3.7, 95% CI 1.2-11.8, p = 0.024). On pre-intervention MRI, vertebral body oedema intensity signal did not influence the outcome. CONCLUSIONS: In patients with persistent and intense pain after an osteoporotic vertebral fracture, early intervention and absence of intravertebral cleft were predictors of favourable outcome at 1 month after vertebroplasty. KEY POINTS: • Performing vertebroplasty within 2 months following a fragility fracture increases success rate. • Presence of an intravertebral cleft at baseline is a predictor of poor mid-term outcome. • A pre-intervention MRI should be performed to ascertain the indication of vertebroplasty.

An open-label, prospective, observational study of the efficacy of bisphosphonate therapy for painful osteoid osteoma.

OBJECTIVES: To assess the efficacy of bisphosphonate therapy on bone pain in patients with osteoid osteoma (OO) (main objective), and to describe bisphosphonate-induced changes in nidus mineralisation and regional bone-marrow oedema (BMO). METHODS: A prospective, observational study was conducted from 2011 to 2014. Patients with risk factors for complications of percutaneous or surgical ablation or recurrence after ablation, were offered once monthly intravenous bisphosphonate treatment until significant pain alleviation was achieved. RESULTS: We included 23 patients. The first two patients received pamidronate and the next 21 zoledronic acid (mean, 2.95 infusions per patient). Bisphosphonate therapy was successful in 19 patients (83%), whose mean pain visual analogue scale score decreased by 76.7%; this pain-relieving effect persisted in 17 patients (74%) with a mean follow-up time of 36 months. Computed tomography (CT) demonstrated a mean nidus density increase of 177.7% (p = 0.001). By magnetic resonance imaging (MRI), mean decreases were 38.4% for BMO surface area and 30.3% for signal intensity (p = 0.001 and p = 0.000, respectively). CONCLUSIONS: In 17/23 patients with painful OO managed conservatively with bisphosphonates, long-term final success was achieved. Bisphosphonates may accelerate the spontaneous healing of OO. KEY POINTS: • 19/23 patients with OO managed with bisphosphonates experienced significant pain relief • Pain relief was sustained in 17/23 patients, mean follow-up of 36 months • CT demonstrated a significant increase in nidus mineralisation • MRI demonstrated a significant decrease in bone marrow oedema • Bisphosphonate therapy may accelerate the spontaneous healing of OO.

Impact of osteoid osteomas of the hip on the size and fatty infiltration of the thigh muscles.

We aimed to assess the impact of osteoid osteomas of the hip on the size and fatty infiltration of the muscle thigh in 42 patients. The thigh circumference, cross-sectional areas, and fatty atrophy of four anterior muscles were assessed on magnetic resonance axial T1-weighted images. A significant fatty atrophy was found in the studied muscles of the ipsilateral thigh except for the rectus femoris. No significant association was demonstrated with pain duration suggesting that muscle atrophy may rather be related to the locoregional inflammation than subsequent to the disuse of the limb.

Periosteum: characteristic imaging findings with emphasis on radiologic-pathologic comparisons.

The periosteum covers most bone structures. It has an outer fibrous layer and an inner cambial layer that exhibits osteogenic activity. The periosteum is a dynamic structure that plays a major role in bone modeling and remodeling under normal conditions. In several disorders such as infections, benign and malignant tumors, and systemic diseases, the osteogenic potential of the periosteum is stimulated and new bone is produced. The newly formed bone added onto the surface of the cortex adopts various configurations depending on the modalities and pace of bone production. Our aim here is to describe the anatomy, histology, and physiology of the periosteum and to review the various patterns of periosteal reaction with emphasis on relations between radiological and histopathological findings. A careful evaluation of the periosteal reaction and appearance of the underlying cortex, in combination with the MRI, clinical, and laboratory data, provides valuable information on lesion duration and aggressiveness, thereby assisting in the etiological diagnosis and optimizing patient management. A solid reaction strongly suggests a benign and slow-growing process that gives the bone enough time to wall off the lesion. Single lamellar reactions occur in acute and usually benign diseases. Multilamellar reactions are associated with intermediate aggressiveness and a growth rate close to the limit of the walling-off capabilities of the bone. Spiculated, interrupted, and complex combined reactions carry the worst prognosis, as they occur in the most aggressive and fast-growing diseases: the periosteum attempts to create new bone but is overwhelmed and may be breached.

Vertebral involvement in Paget's disease: morphological classification of CT and MR appearances.

Vertebral Paget's disease produces a large panel of radiologic appearances sometimes atypical and pseudotumoral. Classical classifications of bone alterations based on pathophysiological hypotheses do not always match the imaging findings. This article will review the computed tomography (CT) and magnetic resonance imaging (MRI) features of Paget's disease of the spine with special emphasis on morphological findings that differentiate Paget's disease from tumors. Combined CT and MRI analyses usually provide the diagnosis of Paget's disease.

Is pain duration associated with morphologic changes of osteoid osteomas at CT?

PURPOSE: To assess the morphologic changes of osteoid osteomas on computed tomographic (CT) scans in association with pain duration. MATERIALS AND METHODS: Institutional review board approval was obtained. Informed consent was waived. From January 2008 to December 2012, 235 patients were treated with interstitial laser ablation at the Hôpital Lariboisière. Ninety-six patients with histopathologically proven osteoid osteomas, complete clinical files, and CT data were studied retrospectively. The following variables were assessed: age, sex, bone location, bone segment, location of the osteoid osteoma in relation to the native cortex, nidus area, nidus calcification area and attenuation at CT, and nidus mineralization ratio (percentage of the calcification area over the total nidus area). Analysis of variance, Kaplan-Meier method, and Cox multivariate regression model were used for statistical analyses. RESULTS: The study sample consisted of 96 patients, 68 of whom were male (71%) and 28 of whom were female (29%) (ratio of male to female patients, 2.4:1). Mean age ± standard deviation was 22.2 years ± 10.4 (range, 4-54 years; median, 18.5 years). The patients' age and nidus mineralization ratio increased significantly with pain duration (hazard ratio, 0.975 [P = .031] and 0.193 [P = .007], respectively). No significant association was found between pain duration and other variables, including the nidus area. In long bones, diaphyseal osteoid osteomas were significantly less mineralized than those in other locations (P = .009). CONCLUSION: The nidus mineralization ratio of osteoid osteomas increases significantly with pain duration and may be a marker of tumor age. Diaphyseal osteoid osteomas demonstrate a lower ratio of nidus mineralization. At the onset of symptoms, older patients experience pain for a longer period before treatment.

Tibial hyperostosis: a diagnostic approach.

Tibial hyperostosis may be encountered in musculoskeletal imaging, incidentally or during the investigation of a leg pain. Hyperostosis involves the exuberant production of osseous tissue and results in cortical, periosteal and/or endosteal thickening of the bone. As a long bone with thick cortices, the tibia has a significant probability of being affected by ubiquitous bone diseases. As a tubular long bone, the tibia is likely to be involved in extensive infectious conditions such as osteomyelitis. As a bone of the lower limb, the tibia undergoes high stresses and may be affected by decrease in bone strength or repetitive submaximal stress. The tibia is also particularly involved in some bone sclerosing dysplasias and Paget's disease. In this work, we aim at highlighting the main conditions leading to tibial hyperostosis and try to provide key elements to narrow down the several diagnostic possibilities. Osteoid osteomas, fatigue or insufficiency fractures, infectious conditions, vascular lesions, sclerosing bone dysplasias and Paget's disease represent the main challenging diagnoses to discuss.

A ganglion of the patellar tendon in patellar tendon-lateral femoral condyle friction syndrome.

Intratendinous ganglia are rare. We report the case of a sedentary woman with chronic mechanical anterolateral pain of the knee and an extensive ganglion of the patellar tendon as indicated on magnetic resonance (MR) and ultrasound (US) examinations. There was evidence of a high-riding patella, patellar malalignment and patellar tendon-lateral femoral condyle friction syndrome with significantly close contact between the patellar tendon and the lateral facet of the femoral trochlea. The ultrasound-guided aspiration of the ganglion enabled a localized injection of an anti-inflammatory drug (cortivazol) and the cytopathological examination of the fluid, which confirmed the diagnosis. Clinical improvement was maintained with knee rehabilitation and was satisfactory at follow-up after 1 year. To our knowledge, we report the first case of a ganglion of the patellar tendon subsequent to patellar tendon-lateral femoral condyle friction syndrome. We found that this case was illustrative of mucoid degeneration in connective tissue due to chronic repetitive microtraumas. Additionally, this case provided the opportunity to discuss the management of this condition in a sedentary individual with a high-riding patella and patellar malalignment.

Plantar fibromatosis may adopt the brain gyriform pattern of a low-grade fibromyxoid sarcoma.

We report the case of a 42-year-old man with histologically proven plantar fibromatosis (Ledderhose disease) demonstrating an uncommon brain gyriform pattern at MRI, so far exclusively described in the low-grade fibromyxoid sarcoma (LGFMS). An acoustic posterior enhancement at ultrasound, a high intensity on T2w and post-contrast T1wMR images were unusual and related to a high tumor cellularity at histology with no myxoid tissue. The juxtaposition of areas of high and low cellularity (with more fibrous material) in a multilobulated mass built a brain gyriform pattern at MR, similar to what was so far described exclusively in LGFMS. This case demonstrates that the brain gyriform pattern may also be observed in other soft tissue fibrous tumors with no myxoid material but with high cellularity areas alternating with fibrous zones of low cellularity.

When should we biopsy a solitary central cartilaginous tumor of long bones? Literature review and management proposal.

Differentiation between benign and low-grade malignant cartilaginous tumors is a radiological and pathological challenge. Based on a literature review, we propose the following guidelines for the management of a solitary central cartilaginous tumor of long bones distinguishing three situations: 1. The tumor is considered to be aggressive and requires surgery if one of the following criteria is present: cortical destruction, Moth-eaten or permeative osteolysis, spontaneous pathologic fracture, periosteal reaction, edema surrounding the tumor on MR images, and soft tissue mass. Tumor biopsy followed by complete intralesional treatment is indicated. 2. The tumor is classified as active if two of the following active criteria are present: pain related to the tumor, endosteal scalloping superior to two-thirds of the cortical thickness, extent of endosteal scalloping superior to two-thirds of the lesion length, cortical thickening and enlargement of the medullary cavity. Tumor biopsy or excision is indicated. 3. The tumor is classified as possibly active if one of the previous active criteria is present. In such cases, bone scintigraphy and dynamic-enhanced MR imaging should be obtained. Radionuclide uptake superior to the anterior iliac crest at bone scintigraphy and early and exponential enhancement at dynamic-enhanced MR are considered as two additional active criteria. After these two examinations, if only one criterion is still present, the lesion can be regarded as possibly quiescent, and the following monitoring is suggested: first follow-up at three to six months and then once a year. Otherwise, if two or more active criteria are present, biopsy is recommended. 4. The tumor is considered quiescent and does not require surgery if no active or aggressive criterion is present. A radiological follow-up can be proposed.

Anatomic variations in the first extensor compartment of the wrist: accuracy of US.

PURPOSE: To evaluate the accuracy of ultrasonography (US) in determining the anatomic variations in the first extensor compartment of the wrist. MATERIALS AND METHODS: Approval from the anatomic donations department was obtained. The first extensor compartment of the wrist of 40 nonembalmed cadaveric forearms (15 male and 25 female; age range at death, 65-100 years) were assessed at US by two observers for the presence or absence of a vertical septum, the presence or absence of an osseous ridge with a double groove in the bony floor, and whether there were single or multiple slips of the abductor pollicis longus and the extensor pollicis brevis tendons. These findings were also evaluated at dissection. RESULTS: The accuracies of US in depicting a septum and an osseous ridge with a double groove were respectively 95% (95% confidence interval [CI]: 83%, 99%) and 100% (95% CI: 91%, 100%). At dissection, a septum was invariably associated with the presence of an osseous ridge. The accuracies of US in depicting multiple tendon slips of the abductor pollicis longus and the extensor pollicis brevis were respectively 80% (95% CI: 64%, 91%) and 97% (95% CI: 86%, 100%). CONCLUSION: US was highly accurate in depicting anatomic variations in the first extensor compartment. US detection of an osseous ridge was an indirect sign of the presence of a septum dividing the first extensor compartment into two subcompartments.

Long-term results of percutaneous resection and interstitial laser ablation of osteoid osteomas.

To evaluate the efficiency and complication rate of two percutaneous treatments of osteoid osteomas, percutaneous trephine resection (PR) and interstitial laser ablation (ILA). Ethical review board was obtained for the retrospective study. One hundred and 26 patients were treated by PR (n = 26) or ILA (n = 100) under CT, with a median follow-up of 113 months for the PR group and 47 months for the ILA group. In the group treated by PR, the clinical success rate was 96% at 6-month and 95% at 24-month follow-up, with 12% (3/26) transient complications (one meralgia, two skin burns). One patient experienced immediate failure, and none had delayed failure. In the group treated by ILA, the clinical success rate was 96% at 6-month and 94% at 24-month follow-up, with 4% (4/100) transient complications (one common fibular nerve contusion, one hematoma, one infection and one tendinitis). Four ILA procedures were repeated, one because of initial failure and three because of recurrence (at 6.5, 15 and 32 months). Two were successful and two failed again. Failure was more frequent (p = 0.0094) in patients less than 18 years old, and in lesions with a nidus size of 12 mm or larger (p = 0.0022).

SAPHO syndrome: MR appearance of vertebral involvement.

PURPOSE: To retrospectively evaluate the magnetic resonance (MR) imaging findings of vertebral involvement in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. MATERIALS AND METHODS: Ethics committee approval and informed patient consent were not required for this retrospective study. MR images obtained in 12 patients (seven female, five male; mean age, 42 years; range, 16-65 years) with SAPHO syndrome involving the spine were reviewed. One vertebral lesion separated by one or more normal vertebrae was analyzed as a distinct lesion. For each lesion, the number of associated vertebrae with abnormal signal intensity (SI) (ie, single vertebra, two adjacent vertebrae, or more than two adjacent vertebrae) was noted. The following MR imaging findings were evaluated: cortical bone erosion, abnormal vertebral body SI compared with normal vertebral body SI, increased anteroposterior diameter of the vertebral body, soft-tissue involvement, vertebral body height loss of more than 30%, and abnormal SI of the adjacent intervertebral disk compared with the SI of the other disks. RESULTS: Of 24 vertebral lesions found, 17 involved a single vertebra, four involved two adjacent vertebrae, and three involved three or four adjacent vertebrae. Vertebral corner cortical erosion was present in all lesions, and 23 (96%) lesions had anterior vertebral corner involvement. The erosion was confined to a vertebral corner in five (21%) lesions and included the adjacent endplate and/or the anterior cortex of the vertebral body in the remaining 19 (79%) lesions. In four (17%) lesions, involvement of two adjacent vertebral corners on either side of an intervertebral disk mimicked to some extent early disk space infection. An adjacent disk space was narrowed in six (25%) lesions and exhibited abnormal SI in two (8%). Prevertebral tissue thickening was observed in eight (33%) lesions. CONCLUSION: Erosion of a vertebral body corner is consistently seen on MR images of SAPHO vertebral lesions and may support the diagnosis of SAPHO syndrome in the appropriate clinical context.

Percutaneous Biopsy of Musculoskeletal Lesions.

Percutaneous biopsy is a minimally invasive technique that yields a high diagnostic accuracy at a relatively low cost in musculoskeletal lesions, especially tumors and infection. In this article, technical refinements improving the results of percutaneous biopsy of musculoskeletal lesions are reviewed, especially the type of radiological guidance, the different biopsy needles available, and the technique of approach depending on the lesion site. Reported complications, results, and indications of musculoskeletal percutaneous biopsy are also discussed.

Percutaneous Biopsy of the Synovial Membrane.

Techniques of percutaneous synovial biopsy under fluoroscopic control of large joints of the limbs (other than the knee) may be useful in arthritis of undetermined etiology especially when infection is considered. Main technical refinements include adequate selection of an optimal approach and biopsy site using new imaging methods, use of a Tru-Cut(R) needle, and placement of the cutting window tangential to the joint surface, and selection of an optimal approach and biopsy site. Detailed technique of the synovial biopsy of hip, ankle, shoulder, and elbow joints is discussed.

Lumbar Chymopapain Chemonucleolysis.

Lumbar chemonucleolysis is an alternative treatment of the sciatic pain due to a disc herniation. It gives good results in 70 to 80% of selected patients. When a correct technique is used, the complication rate is lesser than that of the open surgery. The indications of lumbar chemonucleolysis are larger than in the past and include lateral disc herniations, large or migrated disc herniations, and patients under 18 years or over 60 years. Further studies are necessary to determine if magnetic resonance imaging helps in patients selection and improve the success rate of chemonucleolysis.

Steroid Injection of the Appendicular Skeleton and Sacroiliac Joints.

Steroid joint injections may be effective in painful joints due to degenerative disease and posttraumatic changes, as well as rheumatoid arthritis and seronegative spondylarthropathy. Fluoroscopic guidance may be necessary for deep (sacroiliac, hip, and shoulder) or small (wrist, hand, and foot) joints. Detailed technique of the steroid injection is given, especially for the sacroiliac joint.

Distension Arthrography in Frozen Shoulder Syndrome.

Distension arthrography under fluoroscopic control may be useful in frozen shoulder syndrome. The technique consists of an intra-articular injection of 2 to 3 mL of contrast material, 3 mL of 2% lidocaine, 1.5 mL of cortivazol, and distension of the joint capsule with 30 to 40 mL of refrigerated sterile saline solution. This injection is immediately followed by a physiotherapy program. The authors report their experience of distension arthography in 30 shoulders. Results were good to very good in 90% of cases at 40-day follow-up. No recurrence of a frozen shoulder syndrome was observed and no complications were encountered in this series.

Percutaneous Resection of Osteoid Osteomas.

Osteoid osteomas in almost all locations may be treated by percutaneous resection under CT scan guidance. The authors give their own experience with a series of 30 cases. The different techniques of percutaneous resection reported in the literature are reviewed. Advantages of the percutaneous resection are compared to those of classical surgery and other percutaneous techniques such as lesion destruction with thermocoagulation, photocoagulation, and intralesional injection of alcohol.

Aspiration of Tendinous Calcific Deposits.

Needle aspiration of tendinous calcific deposits under fluoroscopic control may be a valuable tool in selected cases of painful shoulders with chronic and debilitating pain resistant to medical treatment. This article reviews the technique and results of this treatment. The aims of this procedure are (1) to evacuate a maximum amount of calcium; (2) to fragment the residual calcific deposits to facilitate its resorption during the following weeks; (3) to reduce the inflammation secondary to the presence and migration of residual calcific deposits by in situ injection of corticosteroids. Good results are obtained in 61Ð74% of cases. Surgical treatment should be restricted to failures of needle aspiration.