T2-relaxation time of cartilage repair tissue is associated with bone remodeling after spongiosa-augmented matrix-associated autologous chondrocyte implantation.

OBJECTIVE: To investigate whether T2 relaxation time measurements of cartilage repair tissue and structural changes of the knee joint are associated with subchondral bone architecture after spongiosa-augmented matrix-associated autologous chondrocyte implantation (MACI). DESIGN: Both knees of 25 patients (25.5 ± 7.8y; 10 women) were examined preoperatively and 2.7 years after unilateral spongiosa-augmented MACI with 3T magnetic resonance (MR) imaging. Cartilage composition was assessed using T2 relaxation time measurements, subchondral trabecular bone microstructure was quantified using a 3D phase-cycled balanced steady state free-precision sequence. Structural knee joint changes were assessed using the modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used for the postoperative description of the area that underwent MACI. Correlations were assessed using Spearman's rank correlation coefficients. RESULTS: Hypertrophy of the cartilage repair tissue was found in 2 of 25 patients, both after a MACI procedure at the patella, 21 patients showed congruent filling. In subchondral bone of the cartilage repair compartment, apparent trabecular thickness was significantly higher in compartments with elevated cartilage T2 (n = 17; 0.37 ± 0.05 mm) compared to those showing no difference in cartilage T2 compared to the same compartment in the contralateral knee (n = 8; 0.27 ± 0.05 mm; P = 0.042). Significant correlations were found between the overall progression of WORMS and the ipsilateral vs contralateral ratio of average trabecular thickness (r = 0.48, P = 0.031) and bone fraction (r = 0.57, P = 0.007). CONCLUSIONS: After spongiosa-augmented MACI, T2 values of cartilage repair tissue and structural knee joint changes correlated with the quality of the underlying trabecular bone.

Alignment does not influence cartilage T2 in asymptomatic knee joints.

PURPOSE: To investigate whether the static knee alignment affects articular cartilage ultrastructures when measured using T2 relaxation among asymptomatic subjects. METHODS: Both knee joints (n = 96) of 48 asymptomatic volunteers (26 females, 22 males; 25.4 ± 1.7 years; no history of major knee trauma or surgery) were evaluated clinically (Lysholm, Tegner) and by MRI (hip-knee-ankle angle, standard knee protocol, T2 mapping). Group (n = 4) division was as follows: neutral (<1° varus/valgus), mild varus (2°-4° varus), severe varus (>4° varus) and valgus (2°-4° valgus) deformity with n = 12 subjects/group; n = 24 knees/group. Regions of interest (ROI) for T2 assessment were placed within full-thickness cartilage across the whole joint surface and were divided respecting compartmental as well as functional joint anatomy. RESULTS: Leg alignment was 0.7° ± 0.5° varus among neutral, 3.0° ± 0.6° varus among mild varus, 5.0° ± 1.1° varus among severe varus and 2.5° ± 0.7° valgus among valgus group subjects and thus significantly different. No differences between the groups emerged from clinical measures. No morphological pathology was detected in any knee joint. Global T2 values (42.3 ± 2.3; 37.7-47.9 ms) of ROIs placed within every knee joint per subject were not different between alignment groups or between genders, respectively. CONCLUSION: Static frontal plane leg malalignment does not affect cartilage ultrastructure among young, asymptomatic individuals as measured by T2 quantitative imaging. LEVEL OF EVIDENCE: Cross-sectional study, Level II-III.

Bone mineral density measurements of the proximal femur from routine contrast-enhanced MDCT data sets correlate with dual-energy X-ray absorptiometry.

OBJECTIVES: To evaluate the utility of femoral bone mineral density (BMD) measurements in routine contrast-enhanced multi-detector computed tomography (ceMDCT) using dual-energy X-ray absorptiometry (DXA) as the reference standard. METHODS: Forty-one patients (33 women, 8 men) underwent DXA measurement of the proximal femur. Subsequently, transverse sections of routine ceMDCT of these patients were used to measure BMD of the femoral head and femoral neck. The MDCT-to-DXA conversion equations for BMD and T-score were calculated using linear regression analysis. The conversion equations were applied to the MDCT data sets of 382 patients (120 women, 262 men) of whom 74 had osteoporotic fractures. RESULTS: A correlation coefficient of r = 0.84 (P < 0.05) was calculated for BMD(MDCT) values of the femoral head and DXA T-scores of the total proximal femur using the conversion equation T-score = 0.021 × BMD(MDCT) - 5.90. The correlation coefficient for the femoral neck was r = 0.79 (P < 0.05) with the conversion equation T-score = 0.016 × BMD(MDCT) - 4.28. Accordingly, converted T-scores for the femoral neck in patients with versus those without osteoporotic fractures were significantly different (female, -1.83 versus -1.47; male, -1.86 versus -1.47; P < 0.05). CONCLUSION: BMD measurements of the proximal femur were computed in routine contrast-enhanced MDCT and converted to DXA T-scores, which adequately differentiated patients with and without osteoporotic fractures.

Osteolysis after rotator cuff repair with bioabsorbable anchors.

PURPOSE: The current study was designed to evaluate the rate of osteolysis and the clinical and functional outcomes in patients who underwent mini-open rotator cuff repairs using first generation bioabsorbable suture anchors. Our hypothesis was that patients with osteolysis noted on post-repair MRI would have an accompanying decrease in functional and clinical patient outcomes when compared with patients who did not have osteolysis evident on post-repair MRI. TYPE OF STUDY: Clinical retrospective study. METHODS: Between September 2000 and May 2004, 76 patients were repaired using first generation Bio-Corkscrew suture anchors (Arthrex, Naples, FL). 30 patients were available for complete follow-up evaluation. The mean follow-up time was 36 months (range 24-58). Patients were assessed with the Constant-Murley Score, radiographs and magnetic resonance imaging (MRI). Post-operative strength was measured using an Isokinetic Cybex-Dynamometer. 14 patients had osteolysis evident on MRI (Group A) while 16 patients did not have osteolysis on MRI (Group B). RESULTS: In both groups, a total of 70 bio-anchors were used. 22 anchors showed osteolytic changes on MRI (Group A). Concerning ROM, there was no statistical difference in both groups. The Constant-Score was statistically not different in both groups A (92.4) and B (83.7). On MRI-scans, there were repair failures in both groups (A, 2 reruptures; B, 3 reruptures). CONCLUSIONS: Although, we found a high rate of osteolysis after rotator cuff repair with bioabsorbable anchors, these results did not change the clinical outcomes after rotator cuff repair. Recurrent tears were not significantly different in both groups and are comparable to rerupture rates in prior studies. More studies are needed to verify the effect of osteolysis over the long term.

[Clinically unclear painful swelling of the upper arm]. / Klinisch unklare schmerzhafte Schwellung des Oberarms.

In contrast to the intramedullary (80%) and intracortical (14%) subtypes, the subperiostal subtype of aneurysmatic bone cysts (sABC) is relatively rare (6%). Females are affected more frequently than males, whereby the diaphysis is predominantly affected and less frequently the metaphysis of long bones as well as the vertebral column. Especially in conventional radiography sABCs can mimic aggressive lesions. Cross-sectional imaging can potentially reduce the wide range of differential diagnoses. Due to typical imaging features magnetic resonance imaging (MRI) is the most valuable modality to reduce the range of possible differential diagnoses. MRI usually presents a multicystic appearance with a hypointense rim of the lesion, contrast-enhancing cyst walls, fluid levels and edema-like changes in the adjacent tissue. In sABCs with solid components the diagnosis cannot be made with confidence and the suspicion must be confirmed by biopsy. The therapy of primary lesions consists of curettage or the complete excision of the sABC and the defects are subsequently filled with spongiosa or bone cement depending on the size of the lesion.

T2 assessment and clinical outcome following autologous matrix-assisted chondrocyte and osteochondral autograft transplantation.

OBJECTIVE: Both, matrix-assisted chondrocyte transplantation (MACT) and osteochondral autograft transplantation (OCT), are applied for treatment of articular cartilage defects. While previous clinical studies have compared the respective outcome, there is no such information investigating the ultrastructural composition using T2 mapping comparing cartilage T2 values of the repair tissue (RT). METHODS: Eighteen patients that underwent MACT or OCT for treatment of cartilage defects at the knee joint (nine MACT, nine OCT) were matched for gender (one female, eight male pairs), age (33.8), body mass index (BMI) (28.3), defect localization, and postoperative interval (41.6 months). T2 assessment was accomplished by T2 maps, while the clinical evaluation included the Lysholm and Cincinnati knee scores, a visual analogue scale (VAS) for pain, the Tegner activity scale, and the Short Form-36. RESULTS: Global T2 values of healthy femoral cartilage (HC) were similar among groups, while T2 values of the RT following MACT (46.8ms, SD 8.6) were significantly lower when compared to RT T2 values after OCT (55.5ms, SD 6.7) (P=0.048). MACT values were also significantly lower in comparison to HC (52.5ms, SD 7.9) within MACT patients (P=0.046), while OCT values were significantly higher compared to HC (49.9ms, SD 5.1) within OCT patients (P=0.041). The clinical outcome following MACT was consistently superior to that after OCT while only the Lysholm score reached the level of significance (MACT 77.0, OCT 66.8; P=0.04). CONCLUSION: These findings indicate that MACT and OCT result in a different ultrastructural outcome, which is only partially represented by the clinical picture.

Tumour and tumour-like lesions of the patella--a multicentre experience.

Fifty-nine cases of lesions presenting in the patella were identified after review of the databases of four European bone tumour registries. Of the 59 cases, 46% were non neoplastic, 39% were benign and 15% were malignant. The commonest benign neoplasm was giant cell tumour (GCT) (11 cases). Younger patients were more likely to have a benign neoplasm. Lesions in patients less than 40 years of age included giant cell tumour, chondroblastoma, aneurysmal bone cyst (ABC), osteomyelitis, osteoid osteoma and solitary bone cyst. In patients older than 40 years, the following were common lesions: intra-osseous gout, metastasis and intra-osseous ganglion. Expansion of the patella with thinning of cortex was seen more commonly in GCT and brown tumour in hyperparathyroidism. There was associated soft tissue extension in gout and malignant lesions.

Osteochondrosis juvenilis of the medial malleolar epiphysis.

Osteochondrosis juvenilis is caused by a dysfunction of endochondral ossification. Several epiphyses and apophyses can be affected, but osteochondrosis juvenilis of the medial malleolus has not been reported. We describe a 12-year-old boy with bilateral pes planovalgus who was affected by this condition. Conservative management was successful. The presentation, aetiology and treatment are described and the importance of including it in the differential diagnosis is discussed.

Rotator cuff tears: assessment with MR arthrography in 275 patients with arthroscopic correlation.

We assessed the diagnostic performance of magnetic resonance (MR) arthrography in the diagnosis of articular-sided partial-thickness and full-thickness rotator cuff tears in a large symptomatic population. MR arthrograms obtained in 275 patients including a study group of 139 patients with rotator cuff tears proved by arthroscopy and a control group of 136 patients with arthroscopically intact rotator cuff tendons were reviewed in random order. MR imaging was performed on a 1.0 T system (Magnetom Expert, Siemens). MR arthrograms were analyzed by two radiologists in consensus for articular-sided partial-thickness and full-thickness tears of the supraspinatus, infraspinatus, and subscapularis tendons. At arthroscopy, 197 rotator cuff tears were diagnosed, including 105 partial-thickness (93 supraspinatus, nine infraspinatus, three subscapularis) and 92 full-thickness (43 supraspinatus, 20 infraspinatus, 29 subscapularis) tendon tears. For full-thickness tears, sensitivity, specificity, and accuracy were 96%, 99%, and 98%, respectively, and for partial tears 80%, 97%, and 95%, respectively. False negative and positive assessments in the diagnosis of articular-sided partial-thickness tears were predominantly [78% (35/45)] observed with small articular-sided (Ellman grade1) tendon tears. MR arthrography is highly accurate in the diagnosis of full-thickness rotator cuff tears and is accurate in the diagnosis of articular-sided partial-thickness tears. Limitations in the diagnosis of partial-thickness tears are mainly restricted to small articular-sided tears (Ellman grade 1) due to difficulties in differentiation between fiber tearing, tendinitis, synovitic changes, and superficial fraying at tendon margins.

Comparison of multislice CT arthrography and MR arthrography for the detection of articular cartilage lesions of the elbow.

The objective of this study was to compare the value of multislice CT arthrography and MR arthrography in the assessment of cartilage lesions of the elbow joint. Twenty-six cadaveric elbow specimens were examined with the use of CT arthrography and MR arthrography prior to joint exploration and macroscopic inspection of articular cartilage. Findings at CT and MR arthrography were compared with macroscopic assessments in 104 cartilage areas. At macroscopic inspection, 45 cartilage lesions (six grade 2 lesions, 25 grade 3 lesions, 14 grade 4 lesions) and 59 areas of normal articular cartilage were observed. With macroscopic assessment as the gold standard CT and MR arthrography showed an overall sensitivity/specificity of 80/93% and 78/95% for the detection of cartilage lesions, respectively. Only two of six grade 2 lesions were detected by CT and MR arthrography. For the diagnosis of grade 3 and 4 lesions, the sensitivity/specificity was 87/94% with CT arthrography, and 85/95% with MR arthrography. In an experimental setting multislice CT arthrography and MR arthrography showed a similar performance in the detection of cartilage lesions. Both methods indicated limited value in the diagnosis of grade 2 articular cartilage lesions.

Imaging features of subperiosteal aneurysmal bone cyst.

PURPOSE: To analyze the imaging features of subperiosteal aneurysmal bone cyst. MATERIAL AND METHODS: The imaging material of 6 patients with biopsy-proved subperiosteal aneurysmal bone cyst was reviewed. Evaluation included patient demographics, lesion location and size, radiographic features, and intrinsic characteristics on CT and MR images. Review of histologic specimens was carried out by an experienced musculoskeletal pathologist. RESULTS: All lesions were located at the surface of long tubular bones (femur 3, tibia 2, humerus 1): 3 involved the diaphysis, 2 the dia/metaphysis, and 1 exclusively the metaphysis. Lesion size ranged from 2.5 to 6 cm in maximum diameter. Radiographs and CT images always showed a superficial bone defect, which on radiographs demonstrated irregular margins in 4 cases. All lesions caused an interrupted periosteal reaction (shell 3, trabeculated shell 1, Codman angle 2). MR images always showed a multicystic appearance with a hypointense rim, contrast-enhancing cyst walls, and fluid levels. Edema of adjacent soft tissues was present in all cases. CONCLUSION: Aneurysmal bone cyst in a subperiosteal location can demonstrate an aggressive radiographic appearance. MR imaging appears to be most valuable in the differential diagnosis, since it can demonstrate typical morphological features of the underlying process.

Detection of articular cartilage lesions: experimental evaluation of low- and high-field-strength MR imaging at 0.18 and 1.0 T.

The objective of this study was to compare the diagnostic performance of a dedicated orthopedic magnetic resonance (MR) imaging system (0.18 T) and a conventional MR imaging system (1.0 T) in the detection of articular cartilage lesions. Fifty knee joint specimens of pigs with artificially created articular cartilage lesions of different diameters, grades (2-3), and localizations, as well as 50 joints with intact articular cartilage, were imaged at 0. 18 and 1.0 T. Diagnostic performance was determined by means of receiver operating characteristics (ROC) analysis with three independent observers. For none of the pulse sequences used at 0.18 T or 1.0 T areas under ROC curves (A(z)) showed significant differences between the three observers. A(z) values from averaged data were as follows: a) 0.18 T: T1-weighted spin echo (SE): 0.70, proton-density-weighted SE: 0.59, T2-weighted SE: 0.61, two-dimensional (2D) gradient-echo (GRE): 0.73, 3D GRE: 0.75; and b) 1.0 T: T1-weighted SE: 0.73, fat-suppressed T2-weighted turbo-SE: 0. 79, 2D fast low-angle shot (FLASH): 0.79, fat-suppressed 3D FLASH: 0. 96, and water-excited 3D double-echo steady state (DESS): 0.96. With the use of 3D pulse sequences, the high-field system demonstrated a significantly better diagnostic performance than the low-field system in the detection of grades 2 and 3 articular cartilage lesions (P < 0.001).

Osteochondroma: MR imaging of tumor-related complications.

Osteochondromas can be complicated by mechanical irritation, compression or injury of adjacent structures, fracture, malignant transformation, and postoperative recurrence. Magnetic resonance imaging represents the most valuable imaging modality in symptomatic cases, because it can demonstrate typical features of associated soft tissue pathology, which can be differentiated from malignant transformation. Reactive bursae formation presents as an overlying fluid collection with peripheral contrast enhancement. Dislocation, deformation, and signal alterations of adjacent soft tissue structures can be observed in different impingement syndromes caused by osteochondromas. Magnetic resonance imaging provides excellent demonstration of arterial and venous compromise and represents the method of choice in cases with compression of spinal cord, nerve roots, or peripheral nerves, depicting changes in size, position, and signal intensity of the affected neural structures. Malignant transformation as the most worrisome complication occurs in approximately 1% of solitary and 5-25% of multiple osteochondromas. Magnetic resonance imaging is the most accurate method in measuring cartilage cap thickness, which represents an important criterion for differentiation of osteochondromas and exostotic (low-grade) chondrosarcomas. Cartilage cap thickness exceeding 2 cm in adults and 3 cm in children should raise the suspicion for malignant transformation. Finally, MR imaging can detect postoperative recurrence by depiction of a recurrent mass presenting typical morphological features of a cartilage-forming lesion.

Periosteal chondroma: MR characteristics.

PURPOSE: The purpose of this study was to describe the MR characteristics of periosteal chondroma. METHOD: MR images of 12 proven cases of periosteal chondroma were analyzed with reference to tumor morphology and size. MR features were correlated with radiographic and pathologic findings. RESULTS: Tumor size ranged from 1 to 7 cm in maximum diameter with a mean value of 2.6 cm. On MR images, a soft tissue mass at the bone surface with pressure erosion of adjacent cortical bone could be identified in all cases. All lesions were bordered by a hypointense rim (100%) and frequently showed a lobulated configuration (75%). Edema of medullary bone or soft tissues was not observed in any of the cases. Signal intensity of cartilaginous tumor tissue was typically hypo-or isointense relative to muscle on T1-weighted (100%) and hyperintense relative to fat on T2-weighted (92%) and T2*-weighted (100%) MR images. Radiographically significant calcifications of the tumor matrix, present in half of the cases, caused focal signal loss on MR images of all pulse sequences. Contrast enhancement was observed predominantly at the periphery of the lesions (100%), which on pathologic examinations typically contained fibrovascular bundles, surrounding the cartilage lobules. CONCLUSION: Periosteal chondroma appears to have a relatively typical MR appearance, which reflects the histologic composition of the lesion. In addition to radiography, MRI therefore can substantially aid in the preoperative diagnosis of this rare bone lesion.

Osteoid osteoma: CT-guided percutaneous radiofrequency ablation and follow-up in 47 patients.

PURPOSE: To evaluate computed tomography (CT)-guided radiofrequency (RF) ablation as a minimally invasive therapy for osteoid osteoma with regard to technical and clinical success and immediate and delayed complications. MATERIALS AND METHODS: Forty-seven patients (age range, 8-41 y; mean age, 19.6 y) with osteoid osteomas (femur, n = 25; tibia, n = 15; pelvis, n = 2; humerus, n = 1; ulna, n = 1; talus, n = 1; calcaneus, n = 1; vertebral body, n = 1) were treated with CT-guided RF ablation in 15 cases after one (n = 10) or two (n = 5) unsuccessful attempts at open surgical resection. Percutaneous therapy was performed with use of general or spinal anesthesia. After localization of the nidus with 1-3-mm CT sections, osseous access was established with either a 2-mm coaxial drill system or an 11-gauge Jamshidi needle. RF ablation was performed at 90 degrees C for a period of 4-5 minutes with use of a rigid RF electrode with a diameter of 1 mm. The procedures were regarded as technically successful if the tip of the RF electrode could be placed within the center of the nidus and could be heated to the desired temperature. Clinical success of treatment was defined as permanent relief of pain and return to normal function without additional treatment. In case of persistence or recurrence of symptoms after RF ablation, treatment was regarded as secondarily successful if permanent relief of symptoms could be achieved in a second procedure. RESULTS: All procedures were technically successful. Clinical success was achieved in 94% of patients (44 of 47). Three patients had recurrence of pain 3, 5, and 7 months after treatment, respectively (mean observation interval, 22 mo). All recurrences were treated successfully in a second procedure (secondary success rate, 100%). No immediate or delayed complications were observed. CONCLUSION: CT-guided percutaneous RF ablation is a simple, minimally invasive, safe and highly effective technique for treatment of osteoid osteoma.

Malignant fibrous histiocytoma of bone: conventional X-ray and MR imaging features.

OBJECTIVE: To evaluate the conventional X-ray and MR imaging features of malignant fibrous histiocytoma (MFH) of bone. DESIGN: MRI examinations and conventional radiographs were reviewed in 39 patients with biopsy-proven MFH. Imaging characteristics were analyzed and the differential diagnoses assessed in a masked fashion by two experienced radiologists. RESULTS: Typical X-ray features included aggressive, destructive tumor growth centrally located in the metaphysis of long bones. Periosteal reactions and expansive growth were rarely seen. On MR images extraosseous tumor spread was frequently noted. On T2-weighted images and contrast-enhanced T1-weighted images most of the tumors displayed an inhomogeneous, nodular signal pattern with peripheral Gd-DTPA enhancement. CONCLUSIONS: Although several MR imaging criteria were typical for MFH none of them was specific. X-ray diagnosis of MFH may also prove difficult, with the main differential diagnosis being metastasis in the older and osteosarcoma in the younger population.