[Biochemical cartilage imaging-update 2019]. / Biochemische Knorpeldiagnostik ­ Update 2019.

BACKGROUND: Cartilage imaging using magnetic resonance imaging (MRI) is increasingly used for early detection of cartilage damage. Biochemical MR methods to assess cartilage damage are essential for optimal treatment planning. PURPOSE: The aim of this review is to provide an update on advanced cartilage imaging based on biochemical MR techniques. The clinical applications and additional benefits compared to conventional MRI are presented. MATERIALS AND METHODS: A literature search of PubMed regarding the clinical applications of various biochemical MR methods and morphological MR imaging was performed. RESULTS: While T2 mapping can be easily implemented on clinical routine MR scanners, the T1rho method is technically more demanding and is not available on all MR scanners. dGEMRIC, which can be performed with all field strengths, is now severely restricted due to the recent decision of the European Medical Agency (EMA) to withdraw linear gadolinium contrast agents from the market because of proven gadolinium deposition in the brain. Sodium imaging is the most sensitive MRI method for glycosaminoglycan (GAG), but is limited to 7 T. In addition to early diagnosis of cartilage degeneration before morphological changes are visible, biochemical MRI offers predictive markers, e.g., effect of lifestyle changes or assessing results of cartilage repair surgery. CONCLUSION: Cartilage imaging based on biochemical MRI allows a shift from qualitative to quantitative MRI. Biochemical MRI plays an increasingly important role in the early diagnosis of cartilage degeneration for monitoring of disease-modifying drugs and as predictive imaging biomarker in clinical diagnostics. In cartilage repair, monitoring of the efficacy of different cartilage repair surgery techniques to develop hyaline-like cartilage can be performed with biochemical MRI.

[Imaging and classification of avascular femoral head necrosis]. / Bildgebung und Klassifikation der aseptischen Hüftkopfnekrose.

Avascular femoral head necrosis (AVNFH) is difficult to diagnose on plain radiographs in early stages of the disease. Since early stages are often clinically occult, early use of MRI is required to rule out or verify a clinical suspicion. MRI and, in some cases, additional CT are the cornerstones of AVNFH diagnosis and classification. Anteroposterior radiography of the pelvis and a second plane of the involved hip remains the primary basic imaging examination for follow-up and to rule out other pathologies. Correct staging of adult disease has been shown to be the key factor in therapeutic decision-making. According to the German S3 guideline on diagnosis and treatment of AVNFH, use of the ARCO classification is recommended for staging. This paper presents the current status of diagnosis and classification of adult AVNFH. The criteria for ascribing disease to a particular ARCO stage are defined and critically discussed.

S3-Guideline non-traumatic adult femoral head necrosis.

INTRODUCTION: The treatment of adult non-traumatic avascular necrosis of the femoral head (AVN; N-ANFH) within an estimated incidence of 5000-7000 cases per annum in Germany remains a challenge. Risk factors include steroids, alcohol abuse, chemotherapy and immunosuppressive medication, but a genetic predisposition has been suggested. Early diagnosis of this often bilateral disease process is essential for successful conservative or joint preserving surgical management. In this review, we present the update German consensus S3 guideline "diagnosis and management for N-ANFH" as a concise summary. MATERIALS AND METHODS: This systematic review is based on the published literature from January 1, 1970 to April 31, 2013 (German and English language). Inclusion criteria were systematic reviews, meta-analyses and relevant peer review publications. We identified a total of 3715 related publications, of which 422 were suitable according to the SIGN criteria, but only 159 fulfilled our inclusion criteria. RESULTS AND CONCLUSIONS: Clinical suspicion of N-ANFH mandates radiographic evaluation. If radiographs are normal MRI scans are recommended, which should be evaluated according to the ARCO-classification. Differential diagnoses include transient osteoporosis, bone bruise, insufficiency fracture and destructive arthropathy. Untreated, subchondral fractures commonly occur within 2 years, during which the risk for contralateral involvement is high-thereafter unlikely. Conservative management with Ilomedin and Alendronat can be tried, but other pharmacological or physical treatments are inappropriate. No specific joint preserving procedure can be recommended, but core decompression should be considered in early stages if necrosis is <30 %. In ARCO stages IIIc or IV total hip arthroplasty (THA) should be contemplated, which offers similar outcome compared to osteoarthritis. Young age is the main risk factor for higher revision rates after THA for N-ANFH.

[Hereditary vascular malformations: classification, symptoms, diagnostics and prognosis]. / Angeborene Gefäßmalformationen: Klassifikation, Symptome, Diagnostik und Prognose.

The understanding of hereditary vascular anomalies was hampered for a long time by unclear und unspecific terminology. Today, the classification of the International Society for the Study of Vascular Anomalies (ISSVA) differentiates between vascular tumours (mostly infantile haemangioma) with active endothelial proliferation and regression and vascular malformations (VM), which are defects of the vascular morphogenesis and are distinguished in predominantly venous, arterial, capillary, lymphatic, arteriovenous or combined VM. Symptoms are pain, swelling and restricted movement, accompanied by skin signs like dys-plastic veins and capillary VM (naevus flammeus). Thrombophlebitis and chronic venous insufficiency are related to venous VM. Arteriovenous VM are progressive and can cause ischaemic necroses, in rare cases even a high-output cardiac fail-ure. Lymphatic VM lead to localised swelling, in the long run often to recurrent erysipelas and lymphorroea. Primary imaging is provided by -ul-trasound including flow measurements. Mor-phol-ogy and organ involvement is best delineated by magnetic resonance imaging. Phlebography is used to image deep venous system anomalies and is always accompanied by varicography of the dysplastic parts of the venous VM. Digital subtraction angiography is performed to demon-strate the flow pattern in feeding arteries, the nidus and the drainage veins of arteriovenous VM. Besides size and localisation the prognosis of the patients is determined by the pressure (the high-er the pressure, the poorer the prognosis) and the flow rate (the higher the flow rate, the poorer the prognosis) in the VM. Diagnosis and treatment of these rare diseases are best performed in special-ised, interdisciplinary centres.

Endovascular brachytherapy with (192)Ir and (188)Re to treat de novo and recurrent infrainguinal restenoses.

We present a review of the literature on endovascular brachytherapy (EVBT) after percutaneous transluminal angioplasty (PTA) in the femoropopliteal and tibial arteries. The pathophysiological changes induced by PTA and EVBT within the vessel wall, technical considerations regarding 192Ir and 188Re, the results of clinical trials, and the medication required before, during, and after EVBT are summarized.

MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis.

OBJECTIVE: To discuss terminology, radiological differential diagnoses and significance of magnetic resonance imaging (MRI)-detected subchondral bone marrow lesions (BMLs) of the knee joint. METHODS: An overview of the published literature is presented. In addition, the radiological appearance and differential diagnosis of subchondral signal alterations of the knee joint are discussed based on expert consensus. A recommendation for terminology is provided and the relevance of these imaging findings for osteoarthritis (OA) research is emphasized. RESULTS: A multitude of differential diagnoses of subchondral BMLs may present with a similar aspect and signal characteristics. For this reason it is crucial to clearly and specifically define the type of BML that is being assessed and to use terminology that is appropriate to the condition and the pathology. In light of the currently used terminology, supported by histology, it seems appropriate to apply the widely used term "bone marrow lesion" to the different entities of subchondral signal alterations and in addition to specifically and precisely define the analyzed type of BML. Water sensitive sequences such as fat suppressed T2-weighted, proton density-weighted, intermediate-weighted fast spin echo or short tau inversion recovery (STIR) sequences should be applied to assess non-cystic BMLs as only these sequences depict the lesions to their maximum extent. Assessment of subchondral non-cystic ill-defined BMLs on gradient echo-type sequences should be avoided as they will underestimate the size of the lesion. Differential diagnoses of OA related BMLs include traumatic bone contusions and fractures with or without disruption of the articular surface. Osteonecrosis and bone infarcts, inflammation, tumor, transient idiopathic bone marrow edema, red marrow and post-surgical alterations should also be considered. CONCLUSION: Different entities of subchondral BMLs that are of relevance in the context of OA research may be distinguished by specific imaging findings, patient characteristics, symptoms, and history and are discussed in this review.

[Does multi-slice CT provide reliable attenuation values if measured with low slice thickness and low tube current? Results of a phantom study]. / Sind mit der Mehrschicht-Computertomografie Dichtemessungen auch bei geringer Schichtdicke und niedrigem Röhrenstrom verlässlich? Ergebnisse einer Phantomstudie.

PURPOSE: To test whether CT with low slice thickness and low tube current provides reliable attenuation measurements. MATERIALS AND METHODS: Using multi-slice CT and a phantom, we measured the attenuation values of thrombi with different proportions of erythrocytes, using a slice thickness of 1.25 mm, 2.5 mm, and 5 mm with tube currents of 200 mA, 300 mA, and 400 mA and a slice thickness of 0.625 mm with tube currents of 150 mA, 175 mA, and 200 mA. Differences in attenuation values and pixel noise between the three thrombi for tube current and slice thickness were statistically analyzed. RESULTS: The attenuation values of all thrombi increased (p<0.05) when the slice thickness decreased using a tube current of 200 mA or when the tube current decreased using a slice thickness of 1.25 mm. With higher tube currents and thicker slices, the CT values depended on the type of thrombus and the slice thickness. In slices with a thickness of 0.625 mm, the CT values decreased with the tube current in the mixed thrombus with a low proportion of erythrocytes and in the red thrombus (p<0.05). The maximal difference in mean attenuation values was 4.3 HU with a slice thickness of 0.625 mm and 2.2 HU with a slice thickness of 1.25 mm. The pixel noise increased as the slice thickness decreased (p<0.05) with the exception of the red thrombus, if reduced to 0.625 mm. The pixel noise also increased as the tube current decreased (p<0.05) except in mixed thrombi measured with 0.625 mm. The maximal difference in mean standard deviation was 1.8 HU with a slice thickness of 1.25 mm. CONCLUSION: The accuracy of attenuation values as determined by CT with low slice thickness and low tube current with a maximal difference of 4.3 HU suffices for the purposes of clinical routine. A reduction of slice thickness from 1.25 mm to 0.625 mm yields the greatest differences in CT values.

[Virtual colonoscopy--and then? Relevance of small colorectal polyps]. / Virtuelle Koloskopie--Und was dann? Zur Relevanz kleiner kolorektaler Polypen.

UNLABELLED: Colorectal carcinomas are the second most frequent malignant tumors in Germany and originate predominantly from benign polyps (adenoma-carcinoma sequence). Optical colonoscopy is still the gold standard for diagnosis and treatment colorectal polyps. However, CT colonography ("virtual colonoscopy") provides an alternative procedure with similar diagnostic performance but without the possibility of endoscopic polypectomy. Because of the high prevalence (approx. 30 %) of colon polyps in the screening population, virtual colonoscopy is useful for screening only, if a small number of the lesions must be subsequently removed endoscopically. Most of these lesions must represent such a low risk of malignant transformation in order for a control examination to be sufficient. According to a comprehensive review of the literature, the risk potential of small polyps up to a size of 5 - 6 mm can be summarized as follows: Up to 75 % of all polyps found in screening programs belong to the group of "small polyps". Only approx. 1.5-2 % of these contain advanced atypia and less than 0.05 % are carcinomas. Growth speed lies in the range of approx. 0.4 mm in 2 years, but regression can be observed as well. The very few existing growth studies cannot provide reliable information about how quickly these small lesions may turn malignant. CONCLUSION: The risk potential of small polyps can be considered to be low. Nevertheless, because only poor data is available, a definitive statement cannot be made about the spontaneous course of these lesions. Therefore, further studies examining the natural growth behavior of small polyps are necessary, before control examinations (in intervals of two to three years) rather than immediate endoscopic polypectomy can be recommended as an adequate approach in screening programs.

[Do ultrasound-guided core needle biopsies of lymph nodes allow for subclassification of malignant lymphomas?]. / Ist mittels sonografisch gesteuerter Lymphknoten-Stanzbiopsien die Subtypisierung maligner Lymphome möglich?

PURPOSE: We examined how often ultrasound-guided core needle biopsies of lymph nodes yield subclassification of malignant lymphoma according to World Health Organization (WHO) criteria and help to avoid excisional biopsies. MATERIALS AND METHODS: The prospective study included 124 consecutive patients in whom 126 core needle biopsies of lymph nodes were performed to diagnose or rule out malignant lymphoma. If possible, we obtained 5 cylinders with a 14-gauge (G) needle. The pathologists of our institution, partly in cooperation with a lymphoma registry, decided whether a core needle biopsy was sufficient for subclassification or an excisional biopsy was necessary. RESULTS: 95 of the 126 core needle biopsies (76.6 %) were performed with a 14-G needle. In 101 biopsies (80.2 %), we obtained at least 5 cylinders. In 120 of the 126 core needle biopsies (95 %), malignant lymphoma was diagnosed and subclassified or ruled out. Of the 64 lymphoma, 60 (94 %) were subclassified. Among them were 41 (93 %) of the 44 primary lymphomas and 19 (95 %) of the 20 recurrent lymphomas. In 5 of 126 cases (4 %), an excisional biopsy was necessary. CONCLUSION: With ultrasound-guided core needle biopsy of lymph nodes, lymphoma can be reliably diagnosed and subclassified if preferably 5 cores are obtained with 14-G needles. Excisional biopsy is rarely necessary if core needle biopsy is inconclusive.

[Disease-specific Questionnaire for Quality of Life in Patients with Peripheral Arterial Occlusive Disease in the Stage of Critical Ischemia (FLeQKI): psychometric evaluation of its responsiveness and practicability (Part 2)]. / Fragebogen zur gesundheitsbezogenen Lebensqualität von Patienten mit peripherer arterieller Verschlusskrankheit (pAVK) im Stadium kritischer Ischämie (FLeQKI): Psychometrische Bestimmung von Veränderungssensitivität und Praktikabilität (Teil 2).

PURPOSE: To test the "Questionnaire for Life Quality in Patients with Peripheral Arterial Occlusive Disease at the Stage of Critical Ischemia" (FLeQKI) in a prospective study with respect to responsiveness and practicability. PATIENTS AND METHODS: The responsiveness of the FLeQKI for therapy-induced changes of health related quality of life was prospectively determined in 65 consecutive patients with peripheral occlusive arterial disease at the stage of critical ischemia prior to percutaneous transluminal angioplasty (PTA) or bypass operation, and 1 month and 6 months after. 40 healthy individuals who were matched for age and questioned with the FLeQKI twice within 6 months served as the control. Additionally, all patients and healthy volunteers were questioned with the "Medical Outcomes Study Group Short Form" (SF-36). In all patients, the ankle/brachial index (ABI) was measured along with each of the three interviews. To validate practicability, we measured the time needed to fill out the questionnaires and asked the patients to indicate on a visual analog scale (VAS) graduated from 0 - 10 how strenuous they found the questionnaires to be. For statistical analysis, two-sided paired t-tests were used. RESULTS: The treatment group consisted of 35 men and 30 women with an age of 75.1+/-7.0 years, and the control group was comprised of 21 men and 19 women with an age of 73.4+/-7.8 years. In the control group, none of the FLeQKI scales showed significant changes over time (p>0.05). In the pAVK group, all scales improved between the interviews before and 6 months after therapy. Changes were either significant (comorbidity, p<0.05) or highly significant (all other scales, p<0.005 or p<0.0001). ABI increased above 0.5 (p<0.05). With an average of 12 minutes, the FLeQKI required less time than the SF-36 with an average of 15.57 minutes (p<0.05). Both questionnaires were evaluated with a VAS value of less than 1 (p>0.05) as non-strenuous. CONCLUSION: Regarding responsiveness and practicability, the FLeQKI is well suited for determining the specific impairments of life quality in patients with peripheral arterial occlusive disease in the stage of critical ischemia. Compared with the SF-36, the FLeQKI reached similar or better psychometric values.

[Disease-specific Questionnaire for Quality of Life in Patients with Peripheral Arterial Occlusive Disease in the Stage of Critical Ischemia (FLeQKI)--methodical development of a specific measuring instrument and psychometric evaluation of its validity and reliability (Part 1)]. / Fragebogen zur gesundheitsbezogenen Lebensqualität von Patienten mit peripherer arterieller Verschlusskrankheit (pAVK) im Stadium kritischer Ischämie (FLeQKI)--methodische Entwicklung eines krankheitsspezifischen Messinstruments und psychometrische Bestimmung seiner Validität und Reliabilität (Teil 1).

PURPOSE: To develop a disease-specific measuring instrument for quality of life in German-speaking patients with peripheral arterial occlusive disease in the stage of critical ischemia and to test it in a prospective study for validity and reliability. MATERIALS AND METHODS: We developed a questionnaire compiling items representing subjective disease relevant health states. With 35 of these items, we designed the scales comorbidity (KO), physical pain (SZ), physical functioning (KF), physical state (KS), social functioning (SB), mental health (PB), and therapy-induced limitations (TE). Each item was to be valued as never, seldom, often or always. The scales were standardized with a control group of 40 individuals without peripheral arterial occlusive disease who were interviewed twice in an interval of 6 months using both the FLeQKI and the Medical Outcomes Study Group Short Form 36 (SF-36). Convergent and discriminative validity was determined in 65 consecutive in-patients with peripheral occlusive arterial disease in the stage of critical ischemia who were interviewed with FLeQKI and SF-36 prior to percutaneous transluminal angioplasty (PTA) or bypass operation and 1 month and 6 months after. The internal consistency and test-retest reliability of the FLeQKI were determined in the control group. For statistical analysis, Cronbach's alpha Test and Pearsons Product Moment Correlation were used. RESULTS: The control group consisted of 21 men and 19 women with an age of 73.4+/-7.8, and the treatment group was comprised of 35 men and 30 women with an age of 75.1+/-7.0. In the treatment group, convergent validity reached high values in the scales SB, KF, PB, and SZ (r=0.41-0.70). With their discriminative validity (r=-0.04-0.30), TE and KS were independent, specific dimensions of life quality. The control group showed good values for internal consistency (Cronbach's alpha=0.54-0.93) and for test-retest reliability (r=0.44-0.96). CONCLUSION: The FLeQKI is well suited for determining the specific impairments of life quality in patients with peripheral arterial occlusive disease at the stage of critical ischemia. Its psychometric scores for validity and reliability corresponded to those of the SF-36.

[Incidence of major amputations, bypass procedures and percutaneous transluminal angioplasties (PTA) in the treatment of peripheral arterial occlusive disease in a German referral center 1996-2003]. / Inzidenzen von Major-Amputationen, Bypass-Operationen und perkutanen transluminalen Angioplastien (PTA) zur Behandlung der peripheren arteriellen Verschlusskrankheit in einer deutschen Klinik der Maximalversorgung 1996-2003.

PURPOSE: To determine the current incidence of major amputations, bypass procedures and percutaneous transluminal angioplasties (PTA) in a study population of patients with peripheral arterial occlusive disease in a German referral center. MATERIALS AND METHODS: In a retrospective study, we recruited patients with peripheral arterial occlusive disease who underwent an amputation, bypass procedure, or PTA in the region of the pelvis or lower limbs between 1996 and 2003 at the Augsburg Medical Center. Patients were identified via the hospital database. This was performed with the help of the International Classification of Diseases (ICD 9 and 10), the operation code (OPS), and appropriate invoices. The incidence of PTAs was further estimated with 200 charts. RESULTS: Of 5379 patients, 627 underwent amputation, 1832 a bypass procedure, and 2920 a PTA. The incidence of PTAs increased during the study period from 51.3/100 000/year to 64.4/100 000/year (p < 0.01), while the number of amputations and bypass procedures remained stable. The incidence of PTAs was exceeded by that of bypass procedures only in patients older than 85 years. The age of the amputees decreased during the study period from 72.2 to 70.5 years (p < 0.01). The age of patients who underwent a bypass procedure increased from 67.2 to 69.4 years, and the age of patients who underwent PTA increased from 66.3 to 69.8 years (p < 0.01). Bypass procedures and PTAs were performed in men 6.3 years earlier than in women (p < 0.01). CONCLUSION: The result is a population-corrected need of 8.4/100 000/year major amputations, 23/100 000/year bypass procedures and 64.4/100 000/year PTAs for patients with peripheral arterial occlusive disease within the referral area of our hospital. The performance of major amputations and bypass procedures stagnates, while the incidence of PTAs is increasing.

[Percutaneous vertebroplasty for osteoporotic vertebral compression fractures: experiences and prospective clinical outcome in 26 consecutive patients with 50 vertebral fractures]. / Perkutane Vertebroplastie der osteoporotischen Wirbelkörperfraktur: Erfahrungen und prospektive Ergebnisse bei 26 Patienten mit 50 Frakturen.

PURPOSE: Prospective evaluation of vertebroplasty for osteoporotic compression fractures concerning pain reduction, demand of analgesics and quality of life. MATERIAL AND METHODS: In 26 consecutive patients, 50 vertebral fractures were treated by percutaneous vertebroplasty under fluoroscopic (n = 44) or combined fluoroscopic/CT guidance (n = 6). Prospective follow-up was performed after 6 (for 50 vertebral fractures) and 12 months (for 27 vertebral fractures). Visual analogue scale (VAS) and numeric rating scale (NRS) was applied for the assessment of pain. Subjective quality of life and analgesics demand was documented semi-quantitatively. RESULTS: Mean interval from the beginning of pain symptoms to therapy was 8.5 weeks. Vertebroplasty was technically successful in all evaluated patients. Pain severity decreased from 10 (defined at baseline as initial pain score) to 2.8 after 6 months and 2.7 after 12 months. Subjective quality of life was reported as very well, well or improved in 92 % (n = 26 after 6 months) or 100 % (n = 13 after 12 months). No need for additional analgesic therapy was observed in 69.3 % (n = 26) after 6 months and 61.5 % (n = 13) after 12 months. Eight newly developed vertebral fractures were observed during follow-up, with 5 fractures directly adjacent to previously treated vertebrae. Leakage of polymethyl methacrylate (PMMA) into the intervertebral space or spinal canal was observed in 22 % and 20 % respectively (n = 50 vertebrae) . No neurologic deterioration or complications requiring surgery were observed. CONCLUSION: Vertebroplasty is a successful therapeutic approach for the treatment of osteoporotic vertebral fractures. Persistent improvement of clinical symptoms was shown at follow-up after 6 and 12 months.

[Treatment of iatrogenic femoral pseudoaneurysms with thrombin injection--results in 54 patients]. / Die Behandlung iatrogener femoraler Pseudoaneurysmen durch Thrombininjektion -- Ergebnisse bei 54 Patienten.

PURPOSE: To evaluate ultrasound-guided percutaneous thrombin injection to treat iatrogenic femoral pseudoaneurysms following catheter interventions. MATERIALS AND METHODS: In a period of 2 years and 11 months, 55 iatrogenic femoral pseudoaneurysms were treated in 54 patients (male : female = 29 : 25) by percutaneous thrombin injection under continuous color Doppler control. Mean maximum diameter of the perfused lumen was 2.5 cm (SD +/- 1 cm). The injected thrombin doses varied between 10 and 2,000 U (median 200 U). RESULTS: Following thrombin injection, the pseudoaneurysm occlusion rate was 100 % (n = 55/55). Complete and persistent occlusion was achieved in 54 of 55 (98 %) pseudoaneurysms. A repeated procedure was necessary in 6 pseudoaneurysms. In one case (2 %), discrete signs of reperfusion were observed after primary occlusion within 24 hours of the initial procedure (lumen diameter 3 x 5 mm), followed by spontaneous thrombosis without further treatment. No complications, in particular no clinically manifest thromboembolic events, were observed. CONCLUSION: Ultrasound-guided percutaneous thrombin injection is an effective and safe method for the treatment of iatrogenic post catheterization femoral pseudoaneurysms.

[Comparison of contrast-enhanced low mechanical index (Low MI) sonography and unenhanced B-mode sonography for the differentiation between synovitis and joint effusion in patients with rheumatoid arthritis]. / Vergleich von kontrastmittelunterstützter Low-Mechanical-Index(Low-MI)-Sonographie und nativer B-Mode-Sonographie bei der Differenzierung von Synovitis und Gelenkerguss bei Patienten mit rheumatoider Arthritis.

PURPOSE: To test whether contrast-enhanced low mechanical index (low MI) sonography is superior to non enhanced B-Mode sonography in differentiating synovitis and joint effusion. MATERIAL AND METHODS: In a retrospective study, 22 patients with proven rheumatoid arthritis underwent B-Mode sonography and low-MI sonography of 25 symptomatic joints of the upper and lower limbs. For low-MI sonography, 5 ml Sonovue (Bracco Altana Pharma GmbH, Konstanz) were injected as an intravenous bolus followed by 10 ml of 0.9 % saline solution. Magnetic resonance imaging (MRI) was obtained additionally in 3 joints. With non-enhanced sonography, we diagnosed a synovitis in case of an echogenic and a joint effusion in case of an anechoic mass. With contrast-enhanced sonography, we diagnosed a synovitis in case of enhancement and a joint effusion in the absence of enhancement of the intraarticular mass. RESULTS: In 13 joints, synovitis and joint effusion were differentiated by both non-enhanced and enhanced sonography. In 12 joints, this differentiation was only possible with contrast-enhanced sonography. In 3 patients diagnosed by sonography as having a synovitis, this diagnosis was proven by MRI. CONCLUSION: Contrast-enhanced low-MI sonography is superior to non-enhanced B-Mode sonography in differentiating synovitis and joint effusion.

[Influence of clinical information on the diagnostic validity of MRI in the detection of abacterial sacroiliitis]. / Einfluss klinischer Informationen auf die diagnostische Wertigkeit der MRT bei der Frage nach einer abakteriellen Sakroiliitis.

PURPOSE: To evaluate the influence of clinical information on the diagnostic validity of MRI in the detection of abacterial sacroiliitis. Evaluation of sensitivities, specificities, negative (NPV) and positive predictive values (PPV) for MRI with and without clinical information in comparison to a prior defined standard. MATERIALS AND METHODS: The results of routine MRI reports of 65 patients with the clinical suspicion of abacterial sacroiliitis referred by rheumatologists for MR assessment of the sacroiliac joints were retrospectively reviewed. These results were compared to the results of a blinded reading of the same examinations performed without any clinical information. The MRI protocol included T1-SE, STIR and T1-SE contrast-enhanced sequences with fat saturation. All patients were followed for at least four years. The standard of reference was defined by an experienced rheumatologist and included baseline and follow-up data (clinical, laboratory and imaging). Abacterial sacroiliitis was diagnosed in 19 patients. RESULTS: Under routine clinical conditions, MRI revealed a sensitivity of 94.7 % and specificity of 97.8 %. A PPV of 94.7 % and a NPV of 97.8 % were achieved. Without clinical information, MRI revealed a sensitivity and specificity of 64 and 80 %, and a PPV of 49 % and a NPV of 86 %, respectively. CONCLUSION: The additional knowledge of clinical information for the MR diagnosis of abacterial sacroiliitis increases its diagnostic value for the assessment of abacterial sacroiliitis.

Duplex scanning criteria for selection of patients for internal carotid artery endarterectomy.

BACKGROUND: The value of carotid endarterectomy for stroke prevention depends on reliable identification of patients at higher risk for stroke from their internal carotid artery (ICA) occlusive disease than from surgery. This selection of patients is based on the degree of ICA stenosis. Therefore, preoperative diagnostic measures should strive for a prevalence independent probability for disease of 100%. Aim of this prospective study was to obtain clinically applicable duplex scanning criteria for ICA stenosis > or = 70% with a probability for disease of 100%. PATIENTS AND METHODS: In 124 ICA in 62 patients (79% male) angiography and duplex scanning were performed. Degree of stenosis was classified in 4 categories: I < 50%; II 50%-69%; III 70%-99%; IV 100%. Cohen's kappa statistic was used to estimate agreement between both methods within categories. To improve accuracy post-test likelihood for disease was calculated for each point on the receiver operating characteristics (ROC)-curve for peak systolic (PSV) and end-diastolic velocity (EDV), and cut-off points for velocity criteria were set at a positive likelihood of 100%. RESULTS: Diagnostic agreement was good with kappa = 0.77 (95% CI, 0.64-0.90; p < 0.001). For EDV a criterion of > or = 150 cm/sec was associated with a post-test likelihood for disease of 100%. For PSV no appropriate criterion could be detected. CONCLUSIONS: A probability of 100% for ICA stenosis > or = 70% can be achieved by mere preoperative duplex scanning. Vascular laboratory specific validation of duplex scanning criteria should consider prevalence independent post-test likelihood for disease to ensure the value of CEA for stroke prevention.

[S3 Guideline. Part 1: Diagnosis and Differential Diagnosis of Non-Traumatic Adult Femoral Head Necrosis]. / S3-Leitline. Teil 1: Diagnostik und Differenzialdiagnostik der atraumatischen Femurkopfnekrose (aFKN) des Erwachsenen.

Non-traumatic femoral head necrosis (FHN) is primarily a disease of the middle-aged adult. Early diagnosis, at a time with lacking or minimal clinical symptoms, is mandatory to consider conservative therapy or joint preserving operations as a therapeutic option. The new German S3 guideline about diagnosis and therapy of FHN is a cooperative effort of five professional medical societies, overall headed by the Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC). This review (part I/III) cites and explains the statements of the S3 guideline as agreed on the use of imaging methods for diagnosis of FHN. A diagnostic algorithm is presented. FHN clinically has to be considered in case of equivocal pain of a hip joint with a minimum of 6 weeks duration, when risk factors can be revealed, groin pain at clinical investigation, limping, pain or limitation of movement in case of load, and no obvious differential diagnoses. Is an FHN clinically suspected, primarily radiographs of the pelvis ap and a Lauenstein projection of the hip involved should be carried out. When the radiographs are normal, an MRI of the hips should follow routinely. MRI allows the diagnosis of FNH with high accuracy. Furthermore, MRI reveals the site and the size of the necrotic area involved and evaluates the integrity of the joint surface and subchondral fractures. When ARCO stage II (ARCO: Association Research Circulation Osseous) is diagnosed and MRI does not allow one to determine the joint surface with certainty, a CT of the hip joints should be performed. The S3 guideline explains and recommends the use of the ARCO classification. Although, this classification of 1993 is still largely based on radiographs, the pragmatic use of an "extended" version seems reasonable. Today, classical radiographic criteria like impression of the joint surface and subchondral fractures ("crescent sign") are better to be evaluated by MRI, in cases of subtle findings MRI is even surpassed by CT. The extent of the necrosis in the femoral head as well as the size of the surface area involved is best revealed with MRI. Additionally, in the era of cross sectional imaging a stage "0" seems obsolete. The guideline also addresses practically important considerations about the differential diagnosis of misleading MRI findings. This especially holds true for bone marrow oedema in the femoral head which may be misinterpreted. The differentiating features between FHN, transient bone marrow oedema and destructive arthropathy are discussed.

Mechanisms of accumulation of small particles of iron oxide in experimentally induced osteosarcomas of rats: a correlation of magnetic resonance imaging and histology. Preliminary results.

RATIONALE AND OBJECTIVES: This study was conducted to investigate the distribution and kinetics of small particles of iron oxide in osteosarcoma-like tumors. METHODS: Magnetic resonance (MR) imaging was performed in eight athymic nude rats with an experimentally induced osteosarcoma of the right hind leg immediately after intravenous injection of a superparamagnetic iron oxide preparation. Five animals received 150 mumol iron oxide/ kg and three received 50 mumol iron oxide/kg. The iron oxide preparation consisted of polythylenglycol-coated particles with a core diameter of 6 to 8 nm. The MR images were correlated with histologic slices of the tumors. RESULTS: The tumors accumulated iron oxide rapidly. A marked decrease in signal intensity, preferentially along the periphery of the tumor, was followed by a partial return of the signal intensity within the first minute. The maximum signal decrement throughout the entire tumor exceeded 41% and 21% with one dose each of 150 mumol iron/kg and 50 mumol iron/kg, respectively. The rate of return depended on the injected dose and tumor area, with the signal intensity approaching the initial value before the injection of iron oxide after 45 minutes. Histologic correlation only showed deposition of contrast medium in the proliferative areas of the tumors, mainly confined to the tumor margin. In addition to a predominantly extracellular deposition, intracellular storage could be detected. CONCLUSIONS: The findings help to advance the understanding of the distribution and kinetics of intravenous-injected small particles of iron oxide in osteosarcoma-like tumors. A first-pass accumulation of iron oxide could be documented by MR imaging in the periphery of osteosarcomas. Due to sieving of iron oxide particles by liver, spleen, and bone marrow, the signal intensity at 45 minutes after the injection of iron oxide returned to 89% (150 mumol iron oxide/kg) and 95% (50 mumol iron oxide/kg) of the preinjection intensity.

Osteosarcoma of the nude rat. A model for experimental magnetic resonance imaging studies of bone tumors.

A 144cerium-induced osteosarcoma was transplanted to athymic nude rats (Han:rnu/rnu). Nineteen of the tumor-bearing animals were used to demonstrate the characteristics of the osteosarcoma on magnetic resonance imaging (MRI) in comparison with a group of nine animals that had not received any tumor transplant. The tumor-free animals showed homogeneous results in the measurements of their lower legs (T1, 800-898 mseconds; T2, 33-45 mseconds). The osteosarcomas of the tumor-bearing rats were clearly demonstrated and delineated from adjacent structures by MRI at tumor volumes between 0.3 and 7.5 cm3. A significant increase in T1 and T2 relaxation times was found, which corresponded to the increase in tumor volume. T1 relaxation times decreased slightly when tumor volumes reached greater than 5 cm3, whereas T2 relaxation times remained constant at tumor volumes greater than 2.5 cm3. Histologic changes in the structure of the tumors, occurring naturally during their growth, were proven by immersion-fixed sections embedded in paraffin and stained with hematoxylin-eosin. The water content of small and large tumors was determined by lyophilization and heat drying. Both histologic changes and differences in water content were reflected in the variations of relaxation times.