Periosteal Pathologic Conditions: Imaging Findings and Pathophysiology.

The periosteum plays a key role in bone health and is a primary means by which the skeleton responds to a wide range of insults, both benign and malignant. Developmental and histologic features of normal periosteum explain some of the characteristic imaging findings seen in the setting of bone abnormalities. Patterns of periosteal reaction, both in morphology and distribution, are key to distinguishing benign or physiologic periosteal reaction from types of periosteal reaction that warrant further evaluation. The authors review the histologic features, distribution, and development of normal periosteum. Nonaggressive and aggressive types of periosteal reaction are presented with key associations for each. The presence of nonaggressive types of periosteal reaction implies that the underlying process affecting the bone is slow enough that the periosteum is able to heal it or contain it in an organized manner. In contrast, aggressive types of periosteal reaction are seen when the underlying bone insult outpaces the ability of the periosteum to contain it. Image-guided biopsies of lesions with periosteal reaction should be used to sample the site of the most aggressive pattern, as this approach can aid in accurate histologic grading and in detection of tumor cells and bone matrix. The distribution of periosteal abnormalities is as important as the morphology, with a diffuse periosteal reaction favoring systemic causes such as rheumatologic, metabolic, and hematologic conditions compared with a more localized periosteal reaction. Important causes of localized and diffuse periosteal reaction are discussed in a systems-based format, with an emphasis on clinically important causes. © RSNA, 2022.

Periosteum coverage versus collagen-membrane coverage in periodontally accelerated osteogenic orthodontics: a randomized controlled clinical trial in Class II and Class III malocclusions.

BACKGROUND: Periodontal accelerated osteogenic orthodontics (PAOO) is a widely-used clinical procedure that combines selective alveolar corticotomy, particulate bone grafting, and the application of orthodontic forces. Different modifications of PAOO such as collagen-membrane coverage can better benefit patients from preventing displacement of grafts. Due to its stability, collagen-membrane coverage gradually gained popularity and became a widely-used procedure in traditional PAOO technique. OBJECTIVES: To quantitatively investigate the radiographic changes of alveolar bone, periodontal soft tissue changes of the mandibular anterior teeth and postoperative complications in periosteum-covered techniques compared with traditional surgical technique in PAOO. METHODS: Orthodontic camouflage for dental Class II or decompensation for skeletal Class III malocclusions were included; Patients with bone defects on the buccal aspects of the anterior mandible regions confirmed by clinical and radiographic examination were randomly divided into the periosteum coverage group or traditional technique group for PAOO. Cone-beam computerized tomography (CBCT) scans were obtained before treatment (T0) and 1 week (T1) and 12 months (T2) after operation. The primary outcome variable was the vertical alveolar bone level (VBL), the secondary evaluation parameters included labial horizontal bone thickness at the midpoint of the middle third (MHBT) or apical third (AHBT) to the limit of the labial cortical surface during a 12-month follow-up. Postoperative sequelae were evaluated after 2 days and 7 days in both the groups. Periodontal parameters were analyzed at T0 and T2. RESULTS: Thirty-six adult subjects were eligible and recruited in the present study. Although experimental group exhibited more severe infection, no significant differences of the postoperative symptoms or periodontal parameters was found between the 2 groups (P > 0.05). All patients were examined respectively using CBCT at baseline (T0), postoperative 1 week (T1) and 12 months (T2). Both alveolar bone height and width increased from T0 to T1 (P < 0.001) and then reduced from T1 to T2 (P < 0.001) in both groups. However, significant bone augmentation was achieved in each group from T0 to T2 (P < 0.001). Furthermore, the vertical alveolar bone augmentation in the experimental group increased significantly than that in the traditional surgery (P < 0.05). CONCLUSIONS: Compared with traditional PAOO surgery, the periosteum-covered technique provides superior graft stabilization and satisfactory vertical bone augmentation in the labial mandibular anterior area.

Ultrasonography of the bone surface in children: normal and pathological findings in the bone cortex and periosteum.

Ultrasound (US) is widely used in pediatric musculoskeletal pathology at all ages. Although the focus is often on soft tissues, joints and cartilage, the examiner might be confronted with changes in the underlying bone surface that are important to understand and integrate in the diagnosis. This article illustrates the normal US aspects of the cortical bone surface and periosteum, as well as the most common US anomalies seen in infections, trauma and bone tumors in children.

Parosteal lipoma of the forearm: A case report and a literature review.

RATIONALE: Parosteal lipomas are rare neoplasms comprising mature adipocytes situated in a proximity to bone. Although these tumors follow a benign course, the reactive osseous changes that may occur with such lesions might raise the suspicion of malignancy. PATIENT CONCERNS: Here we present a case of a 33-year-old male patient complaining of pain and swelling in the right anterior forearm without history of trauma. DIAGNOSIS: An magnetic resonance imaging of the region revealed a lobulated intramuscular fat intensity mass within the supinator muscle. Bony projection inseparable from the anterolateral radial diaphyseal cortex and periosteum was also seen. The radiological features suggested the diagnosis of parosteal lipoma. INTERVENTION: After the radiological diagnosis of a parosteal lipoma, the patient was offered a total surgical excision of the mass. OUTCOMES: The mass was removed successfully. Histopathology showed mature benign adipose tissue bordered by thin fibrous septa confirming the diagnosis of parosteal lipoma. Follow-up magnetic resonance imaging after 6 months did not reveal any signs of complications or recurrence. LESSONS: Distinction of the features of parosteal lipomas is needed to establish the accurate diagnosis, discriminate it from malignant lesions, predict potential neurovascular compromises, and follow up until a curative action is planned.

[Periosteum entrapped in growth plate cartilage in patients with epiphyseal fracture-separation: about a case]. / Incarcération du périoste dans le cartilage de croissance dans une fracture-décollement épiphysaire: à propos d'un cas.

Foreign body entrapment in growth plate cartilage is a rare disease. It often occurs in patients with epiphyseal separation. Its diagnosis is radiological, based on brain magnetic resonance imaging (MRI). We here report a case of a 13-year-old girl who presented with a painful left post traumatic knee. The clinical examination and the standard radiographs performed were in favor of a Salter-Harris type 1 epiphyseal detachment. The first-line treatment, which consisted of immobilization in a cast for three weeks, was unsatisfactory. Faced with this therapeutic failure, an MRI was performed and demonstrated an incarceration of a foreign body in the conjugation cartilage. Secondary management was based on surgery, without sequelae.

Minimally invasive treatment of long bone non-unions with bone marrow concentrate, demineralized bone matrix and platelet-rich fibrin in 38 patients.

To determine the efficacy of percutaneous injection of autologous bone marrow concentrated (BMC), demineralized bone matrix (DBM), and platelet rich fibrin (PRF) in the treatment of long bone non-unions. From January 2011 to January 2018 patients with non-union of the lower limbs who were on the waiting list for open grafting with established tibial or femoral non-union and minimal deformity were eligible to participate in this study. Patients were treated with a single percutaneous injection of DBM, BMC and PRF. Our study group comprised 38 patients (26 males and 12 females; mean age 39, range 18 to 65). Non-unions were located in the femur (18 cases) and in the tibia (20 cases). Clinical and imaging follow-up ranged from 4 to 60 months (mean 20 months). Bone union occurred in 30 out of 38 patients (79%) in an average of 7 months (range 3 to 12) and all healed patients had full weight bearing after 9 months on average (range 6 to 12) from injection. In 19 cases the osteosynthesis was removed 12 months on average (range 3 to 36) from surgery. One patient developed infection at the non-union site after treatment. Percutaneous injection of DBM, BMC, and PRF is an effective treatment for long-bone non-unions. This technique allows the bone to heal with a minimally invasive approach and with a hospitalization of 2 days. Key elements of bone regeneration consist of a combination of biological and biomechanical therapeutic approach.

Associations Between Periosteal Reaction of Proximal Tibial and Medial Compartment Knee Osteoarthritis.

OBJECTIVE: To evaluate and analyze the potential relationship between periosteal reaction and medial compartment knee osteoarthritis (KOA), and to assess the independent risk factors for the development of periosteal reaction associated with medial compartment KOA. METHODS: This is a retrospective comparative study. From January 2019 to December 2019 at the Third Hospital of Hebei Medical University, a total of 363 patients (726 knees) with medial compartment KOA were enrolled in this study according to our inclusion and exclusion criteria, including 91 males and 272 females, with an mean age of 57.9 ± 12.8 years (range, 18-82 years). Among these patients, 206 patients (412 knees) were allocated to the periosteal reaction group (44 males and 162 females) and 157 patients (314 knees) were allocated to the non-periosteal reaction group (47 males and 110 females). The classification of KOA severity was based on Kellgren and Lawrence (K-L) grading system. The malalignment of the lower extremities in coronal plane was evaluated as medial proximal tibial angle (MPTA), hip-knee-ankle angle (HKA), and lateral distal femoral angle (LDFA). Patients demographics and radiographic parameters were recorded in the two groups. Intra-observer and inter-observer reliabilities of all radiological measurements were analyzed by intraclass correlation coefficients (ICCs). Univariate analyses were conducted for comparison of differences with continuous variables between patients with periosteal reaction and without periosteal reaction. Multivariate logistical regression analysis was performed to determine the independent risk factors of radiographic parameters for periosteal reaction. RESULTS: The overall incidence of periosteal reaction associated with medial compartment KOA was 56.7%. Furthermore, we observed that the incidence of periosteal reaction significantly increased with age and correlated with K-L grade progression (P < 0.05). There was a statistically significant difference between the two groups. In the multivariate logistical regression analysis, HKA and JLCA were identified as independent risk factors of the development of periosteal reaction in patients with medial compartment KOA (odds ratio [OR], 0.594; 95% confidence interval [CI] 0.544-0.648; P < 0.05; OR, 0.851; 95% confidence interval CI 0.737-0.983; P < 0.05; respectively), with other radiographic parameters including MTPA (OR 0.959; 95% CI 0.511-0.648; P > 0.05), LDFA (OR 0.990; 95% CI 0.899-1.089; P > 0.05), and JSW (OR 1.005; 95% CI 0.865-1.167; P > 0.05). CONCLUSIONS: In this retrospective study, patients with lower HKA and higher JLCA were identified as independent risk factors for the development of periosteal reaction, which occurred most commonly adjacent to the lateral of proximal tibia diaphysis, and thus we concluded that periosteal reaction may be an anatomical adaptation for medial compartment KOA based upon these results.

Spontaneous subperiosteal orbital hematoma in a patient with chronic sinusitis.

Periorbital swelling is a common presentation to the emergency department (ED), and its etiology can range from benign to acutely vision-threatening. Orbital subperiosteal hematoma is a rare ED diagnosis that is typically associated with trauma, though can infrequently occur spontaneously in the setting of sudden elevations in cranial venous pressure, bleeding diathesis, and sinusitis. We present a case of a 55-year-old female with a history of chronic sinusitis who presented to the ED with a three-day history of left-sided periorbital swelling along with painful extraocular movements and markedly decreased visual acuity following a cross-country road trip through elevation. Contrast computed tomography scan of the orbits revealed a large extraconal collection in the subperiosteal space causing significant mass effect on the left globe, along with findings of diffuse sinonasal disease bilaterally. Intravenous antibiotics were started immediately and the patient underwent surgical incision and drainage of the subperiosteal space, where she was diagnosed with a spontaneous subperiosteal orbital hematoma secondary to chronic sinusitis. Within the literature, there are fewer than 20 case reports of orbital subperiosteal hematoma secondary to sinusitis. The purpose of this case report is to assist emergency physicians in considering the rare but potentially vision-threatening condition of spontaneous subperiosteal orbital hematoma within their differential diagnosis of patients with periorbital swelling and proptosis, as well as to provide an approach to management within the ED.

Pain, osteolysis, and periosteal reaction are associated with the STRYDE limb lengthening nail: a nationwide cross-sectional study.

Background and purpose - Observing serious adverse events during treatment with the Precice Stryde bone lengthening nail (NuVasive, San Diego, CA, USA), we conducted a nationwide cross-sectional study to report the prevalence of adverse events from all 30 bone segments in 27 patients treated in Denmark.Patients and methods - Radiographs of all bone segments were evaluated regarding radiographic changes in February 2021. We determined the number of bone segments with late onset of pain and/or radiographically confirmed osteolysis, periosteal reaction, or cortical hypertrophy in the junctional area of the nail.Results - In 30 bone segments of 27 patients we observed radiographic changes in 21/30 segments of 20/27 patients, i.e., 19/30 osteolysis, 12/30 periosteal reaction (most often multi-layered), and 12/30 cortical hypertrophy in the area of the junction between the telescoping nail parts. Late onset of pain was a prominent feature in 8 patients. This is likely to be a prodrome to the bony changes. Discoloration (potential corrosion) at the nail interface was observed in multiple removed nails. 15/30 nails were still at risk of developing complications, i.e., were not yet removed.Interpretation - All Stryde nails should be monitored at regular intervals until removal. Onset of pain at late stages of limb lengthening, i.e., consolidation of the regenerate, should warrant immediate radiographic examination regarding osteolysis, periosteal reaction, and cortical hypertrophy, which may be associated with discoloration (potential corrosion) of the nail. We recommend removal of Stryde implants as early as possible after consolidation of the regenerate.

Depiction of the Periosteum Using Ultrashort Echo Time Pulse Sequence with Three-Dimensional Cone Trajectory and Histologic Correlation in a Porcine Model.

OBJECTIVE: To evaluate the signal intensity of the periosteum using ultrashort echo time pulse sequence with three-dimensional cone trajectory (3D UTE) with or without fat suppression (FS) to distinguish from artifacts in porcine tibias. MATERIALS AND METHODS: The periosteum and overlying soft tissue of three porcine lower legs were partially peeled away from the tibial cortex. Another porcine tibia was prepared as three segments: with an intact periosteum outer and inner layer, with an intact periosteum inner layer, and without periosteum. Axial T1 weighted sequence (T1 WI) and 3D UTE (FS) were performed. Another porcine tibia without periosteum was prepared and subjected to 3D UTE (FS) and T1 WI twice, with positional changes. Two radiologists analyzed images to reach a consensus. RESULTS: The three periosteal tissues that were partially peeled away from the cortex showed a high signal in 3D UTE (FS) and low signal on T1 WI. 3D UTE (FS) showed a high signal around the cortical surface with an intact outer and inner periosteum, and subtle high signals, mainly around the upper cortical surfaces with the inner layer of the periosteum and without periosteum. T1 WI showed no signal around the cortical surfaces, regardless of the periosteum state. The porcine tibia without periosteum showed changes in the high signal area around the cortical surface as the position changed in 3D UTE (FS). No signal was detected around the cortical surface in T1 WI, regardless of the position change. CONCLUSION: The periosteum showed a high signal in 3D UTE and 3D UTE FS that overlapped with artifacts around the cortical bone.

Parosteal osteosarcoma with a manifestation of subperiosteal low-grade central osteosarcoma.

We report the peculiar case of a parosteal osteosarcoma arising beneath the periosteum in a 12-year-old boy. He complained of difficulty in left knee flexion. Plain radiography showed a uniformly dense mineralized mass in the bone cortex and parosteal ossified nodules at the metaphysis and diaphysis of the left distal femur. Periosteal reaction was not evident. Uniquely, plain radiography had a smooth outline and revealed gradually thickening mass toward the center. Histologically, the tumor showed a proliferation of spindle-shaped cells with parallel-oriented dense bone trabeculae and hyaline cartilaginous tissue disclosing mild atypia. The periosteum was inverted along the polypoid mass, but there was no periosteum at the top. Immunohistochemically, the spindle cells, including those at the top of the polypoid mass, and cartilaginous cells were positive for MDM2 and CDK4. MDM2 gene amplification was detected in these cells by fluorescence in situ hybridization. Despite the peculiar feature of plain radiography, the lesion was diagnosed as parosteal osteosarcoma. This case report presents a case of parosteal osteosarcoma arising beneath the periosteum, although it is postulated to arise in the outer layer of the periosteum. The unique radiographic findings in this case suggest an association of parosteal osteosarcoma with vigorous bone growth before closure of the growth plate.

Changes in the intra- and peri-cellular sclerostin distribution in lacuno-canalicular system induced by mechanical unloading.

INTRODUCTION: Mechanical stimuli regulate Sclerostin (Scl), a negative regulator of bone formation, expression in osteocytes. However, the detailed Scl distribution in osteocytes in response to mechanical unloading remains unclear. MATERIALS AND METHODS: Twelve-week-old male rats were used. The sciatic and femoral nerves on the right side were excised as mechanical unloading treatment. A sham operation was performed on the left side. One week after neurotrauma, the bone density of the femora was evaluated by peripheral quantitative computed tomography, and immunofluorescence was performed in coronal sections of the femoral diaphysis. The mean fluorescence intensity and fluorescent profile of Scl from the marrow to the periosteal side were analyzed to estimate the Scl expression and determine to which side (marrow or periosteal) the Scl prefers to distribute in response to mechanical unloading. The most sensitive region indicated by the immunofluorescence results was further investigated by transmission electron microscopy (TEM) with immunogold staining to show the Scl expression changes in different subcellular structures. RESULTS: In femur distal metaphysis, neurotrauma-induced mechanical unloading significantly decreased the bone density, made the distribution of Scl closer to the marrow on the anterior and medial side, and increased the Scl expression only on the lateral side. TEM findings showed that only the expression of Scl in canaliculi was increased by mechanical unloading. CONCLUSIONS: Our results showed that even short-term mechanical unloading is enough to decrease bone density, and mechanical unloading not only regulated the Scl expression but also changed the Scl distribution in both the osteocyte network and subcellular structures.

Canine calvarial subperiosteal hematomas are fluid to soft tissue attenuating mass-like lesions with smoothly marginated peripheral mineralization on CT.

Subperiosteal hematomas are accumulations of blood between a bone and the periosteum leading to elevation of the periosteum. When ossified they have a mineralized outer rim. For this retrospective, multi-institutional case series, medical records were searched to identify dogs that underwent CT for focal calvarial swellings noted acutely after trauma. A total of four dogs were included. Computed tomography images were reviewed for each case. The focal swellings had progressed in size during the weeks after the head trauma until the time of imaging. Findings in all cases included a fluid to soft tissue attenuating mass-like lesion with smoothly marginated peripheral mineralization. Diagnosis was confirmed in two cases by cytology and/or histopathology. Therefore, authors recommend that subperiosteal hematoma be included in the differential diagnosis list for dogs with these clinical and CT characteristics. Based on our review of the literature, this is the first report to describe the CT features of calvarial subperiosteal hematomas in dogs.

Idiopathic Orbital Inflammation Appearing on the Affected Side of Preceding Myasthenia Gravis.

The patient was a 70-year-old man with idiopathic orbital inflammation (IOI) that appeared on the severely affected side of preceding myasthenia gravis (MG). The patient was diagnosed with MG 5 years prior to the onset of IOI. When IOI was diagnosed, an edrophonium test was negative. IOI was considered because he complained of left orbital pain, eyelid swelling, and cerebral MRI exhibited the enhanced lesions along the left orbital periosteum. A biopsy specimen revealed pathological findings compatible with IOI. The administration of corticosteroids was effective for improving the ocular symptoms. IOI should be considered when ocular symptoms deteriorated with soft tissue swelling/pain in MG patients.

Temporal Evolution of Imaging Findings in Ossified Cephalohematoma.

BACKGROUND: Cephalohematoma is collection of blood between skull and periosteum that is confined by cranial sutures. Cephalohematomas usually resorb spontaneously within the first month of life; however, if it fails to resolve, ossified cephalohematoma may form. METHODS: Clinical archiving system and picture archiving and communication system were retrospectively reviewed for cases of birth-related cephalohematoma. Cases of ossified cephalohematomas identified on imaging were retrieved from this subset of patients. Cross-sectional imaging findings in patients with ossified cephalohematomas were evaluated for location, size of the hematoma, and contours of the inner lamella. RESULTS: Out of 115 cases of cephalohematoma, 7 cases had imaging findings consistent with ossified cephalohematoma. All ossified cephalohematomas were located parietally, with size ranging between 18 and 55 mm and the thickness of the outer rim of calcification ranging between 1.5 and 4.8 mm. The contour of inner lamella in relation to the surrounding normal cranial vault was normal in 5 cases, and inner lamella was depressed in 2 cases.Three patients had follow-up imaging available for demonstration of changes in ossified cephalohematoma. The first case was an 11 day-old boy with a cephalohematoma with no signs of calcification at the time of initial imaging. Follow-up at 2 months of age showed partial regression of hematoma cavity with marked calcification at the hematoma walls. The second case was a 3 month-old boy with ossified cephalohematoma at initial imaging. Follow-up imaging at 7 months of age showed almost total regression of hematoma cavity, and approximation of inner and outer lamella with increased thickness of the cranial vault. The third case was a 1 month-old boy with ossified cephalohematoma at initial imaging that totally resolved without residual increased bone thickness at 21-month follow-up. CONCLUSION: These 3 cases demonstrate the variability in temporal changes that may occur in ossified cephalohematomas.

Preparation and evaluation of acellular sheep periostea for guided bone regeneration.

The objective of this study was to fabricate an acellular sheep periosteum and explore its potential application in guided bone regeneration. Sheep periosteum was collected and decellularized by a modified decellularization protocol. The effectiveness of cell removal was proved by hematoxylin and eosin and 4',6-diamidino-2-phenylindole staining, DNA quantitative test, and agarose gel electrophoresis. After decellularization, its microstructure was found to become more porous while the integrality of collagen fibers remained undamaged, and the contents of collagen and glycosaminoglycan were not decreased significantly. Biomechanical analysis showed that the elastic modulus was significantly declined, while the yield stress was not affected, probably due to the collagen integrality. In vitro study of CCK-8 assay demonstrated that the acellular periosteum not only had no toxic effect to the MC3T3-E1 cells, but benefited the cell proliferation to some degree. In vivo experiment of guided bone regeneration was performed using a rabbit cranial model. Micro-CT and histological results revealed that the acellular periosteum not only effectively prevented the ingrowth of fibrous connective tissues, but also potentially facilitated bone regeneration. In conclusion, acellular sheep periostea, with wider sources, less costs, and more convenient fabrication process, would have great potential in the employment for guided bone regeneration.

It's time to recognize the perichondrium.

The perichondrium is a complex structure centered at the chondro-osseous junction of growing bones. It plays an important role in both normal skeletal development and in pathological conditions. This review illustrates the normal anatomy, function and imaging appearance of the perichondrium from fetal development to older childhood. The radiologic appearance of the perichondrium in skeletal trauma, infection and tumors in which it plays a role also are reviewed.

MRI with state-of-the-art metal artifact reduction after total hip arthroplasty: periprosthetic findings in asymptomatic and symptomatic patients.

OBJECTIVES: To assess the spectrum of periprosthetic MRI findings after primary total hip arthroplasty (THA). METHODS: This multi-center cohort study analyzed 31 asymptomatic patients (65.7 ± 12.7 years) and 27 symptomatic patients (62.3 ± 11.9 years) between 6 months and 2 years after THA. 1.5-T MRI was performed using Compressed Sensing SEMAC and high-bandwidth sequences. Femoral stem and acetabular cup were assessed for bone marrow edema, osteolysis, and periosteal reaction in Gruen zones and DeLee and Charnley zones. Student t test and Fisher's exact test were performed. RESULTS: The asymptomatic and symptomatic groups showed different patterns of imaging findings. Bone marrow edema was seen in 19/31 (61.3%) asymptomatic and 22/27 (81.5%) symptomatic patients, most commonly in Gruen zones 1, 7, and 8 (p ≥ 0.18). Osteolysis occurred in 14/31 (45.2%) asymptomatic and 14/27 (51.9%) symptomatic patients and was significantly more common in Gruen zone 7 in the symptomatic group (8/27 (29.6%)) compared to the asymptomatic group (2/31 (6.5%)) (p = 0.03). Periosteal reaction was present in 4/31 asymptomatic (12.9%) and 9/27 symptomatic patients (33.3%) and more common in Gruen zones 5 and 6 in the symptomatic group (p = 0.04 and 0.02, respectively). In the acetabulum, bone marrow edema pattern was encountered in 3/27 (11.1%) symptomatic patients but not in asymptomatic patients (p ≥ 0.21). Patient management was altered in 8/27 (29.6%) patients based on MRI findings. CONCLUSIONS: Periprosthetic bone marrow edema is common after THA both in asymptomatic and symptomatic patients. Osteolysis and periosteal reaction are more frequent in symptomatic patients. MRI findings led to altered patient management in 29.6% of patients. KEY POINTS: • Bone marrow edema pattern was frequent in both asymptomatic and symptomatic patients after THA, particularly around the proximal femoral stem in Gruen zones 1, 7, and 8. • Osteolysis was significantly more frequent in symptomatic patients in Gruen zone 7. • Periosteal reaction occurred more frequently in symptomatic patients in Gruen zones 5 and 6.