Demonstration of transverse ligament on 3D SPACE MRI in whiplash-associated disorder and nontraumatic conditions.

PURPOSE: This study aims to delineate the three-dimensional (3D) SPACE MRI findings of the transverse ligament (TL) in whiplash-associated disorder (WAD) patients, and to compare them with those from a nontraumatic group. METHODS: A retrospective analysis was performed on cervical spine MRI scans obtained from 46 patients with WAD and 62 nontraumatic individuals. Clinical features, including the WAD grade and stage, were recorded. The TL's morphological grade and the symmetricity of the lateral atlantodental interval was assessed using axial 3D T2-SPACE images. The morphological grading was evaluated using a four-point scale: 0 = homogeneously low signal intensity with normal thickness, 1 = high signal intensity with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures. Additionally, the number of cervical levels exhibiting degeneration was documented. RESULTS: When comparing the WAD and nontraumatic groups, a significant difference was observed in the proportion of high-grade TL changes (grade 2 or 3) and the number of degenerated cervical levels. Logistic regression analysis revealed that high-grade TL changes and a lower number of degenerative levels independently predicted the presence of WAD. Within the WAD group, the subset of patients with high-grade TL changes demonstrated a significantly higher mean age than the low-grade group (grade 0 or 1). CONCLUSION: High-grade morphological changes in the TL can be detected in patients with WAD through the use of 3D SPACE sequences. Clinical relevance statement 3D SPACE MRI could serve as an instrumental tool in the assessment of TL among patients with WAD. Integrating MRI findings with patient history and symptomology could facilitate the identification of potential ligament damage, and may help treatment and follow-up planning.

Comparison between 2D TSE and 3D SPACE in the evaluation of craniocervical ligaments.

PURPOSE: To evaluate the MRI findings of the craniocervical junction ligaments and compare the 2D TSE sequence and 3D SPACE sequence on cervical spine MRI. METHODS: Eighty cervical spine MRIs were retrospectively analyzed, including 2D TSE and 3D SPACE sequences. The visibility and morphology of the transverse ligament (TL) and alar ligament (AL) were evaluated by two readers using a five-point grading scale for visibility (1 = not visible, 2 = barely visible, 3 = adequately visible, 4 = good visibility, 5 = excellent visibility) and a four-point grading scale for morphology (0 = homogeneous low SI with normal thickness, 1 = high SI with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures). The grades of the two sequences were compared. Reader agreements were measured using the percentage of exact agreement. RESULT: The visibility grade of TL was significantly higher in 3D, indicating better visualization. The morphology grade of TL was significantly lower in the 3D, indicating more normal-appearing ligament. The exact agreements of visibility and morphology grade of TL tended to be higher in 3D. On the other hand, there was no significant difference in visibility grade of AL between the two sequences. The morphological grade of AL was significantly higher in 3D. The agreement of the morphological grade of AL tended to be lower in 3D. CONCLUSION: The utilization of 3D sequences significantly improves the visibility of TL and could potentially reduce false-positive diagnoses of ligament injury.

Hip Magnetic Resonance Arthrography Using Normal Saline Is Less Accurate Than Using a Gadolinium-Based Contrast Agent.

PURPOSE: To evaluate the diagnostic performance of hip magnetic resonance (MR) arthrography with a gadolinium-based contrast agent (GBCA) or normal saline (NS) for intra-articular pathologies. METHODS: This retrospective study was approved by the institutional review board of our hospital, and the requirement for informed consent was waived. The study included 37 consecutive patients (38 hips; 21 right hips; 24 males; mean age, 33 years) who underwent GBCA-hip MR arthrography from July 2011 to January 2020 and 30 consecutive patients (30 hips; 20 right hips; 21 males; mean age, 40 years) who underwent NS-hip MR arthrography from January 2018 to June 2020. All images were evaluated twice independently by two radiologists blinded to the arthroscopic findings for the presence of labral tears, cartilage abnormalities, or ligamentum teres tears. Intrareader and interreader reliabilities were determined by kappa values (k) using the chi-squared test, and diagnostic performance was evaluated based on the arthroscopic findings. A P value less than .05 was considered to indicate statistical significance. RESULTS: Intra-reader reliability in the detection of intra-articular pathologies ranged from moderate to almost perfect (k = 0.510-0.840) and inter-reader reliability ranged from moderate to substantial (k = 0.441-0.695) for GBCA- and NS-hip MR arthrography. The diagnostic accuracy of GBCA- and NS-hip MR arthrography was as follows: 81.6-92.1% and 66.7-73.3% for labral tears, respectively; 68.4-86.8% and 63.3-70.0% for cartilage abnormality, respectively; and 68.4-76.3% and 50.0-56.7% for ligamentum teres tears, respectively. CONCLUSION: NS-hip MR arthrography may be less accurate than GBCA-hip MR arthrography. LEVEL OF EVIDENCE: Level II of development of diagnostic criteria (consecutive patients with consistently applied reference standard and blinding).

Diagnosing ulnar neuropathy at the elbow on MRI: importance of the longitudinal extent of the hyperintense ulnar nerve.

OBJECTIVE: To evaluate the usefulness of the longitudinal extent (LE) of high ulnar nerve signal intensity (SI) for the diagnosis of ulnar neuropathy at the elbow (UNE). MATERIALS AND METHODS: This retrospective study included 68 patients who underwent elbow MRI. Twenty-seven and 41 patients were enrolled in the UNE and control groups, respectively. Qualitative and quantitative analyses of the SI and size of the ulnar nerve at the cubital tunnel, proximal, and distal to the cubital tunnel were performed. Cross-sectional area (CSA) and nerve-to-muscle contrast ratio (NMCR) were measured at each level. The LE of the hyperintense ulnar nerve was evaluated using axial and coronal images. The presence of space-occupying lesions (SOLs), subluxation, and muscle denervation were recorded. Univariate and multivariate analyses were performed to identify independent predictive factors. RESULTS: Ulnar nerve hyperintensity at and distal to the cubital tunnel, presence of compression, SOL, muscle denervation, LE of hyperintense ulnar nerve, NMCR, and CSA at and distal to the cubital tunnel significantly differed between the two groups. Multivariate logistic regression analysis showed that the LE of the hyperintense ulnar nerve and CSA at the cubital tunnel were independent predictive factors for UNE (p < 0.05). CONCLUSION: LE of the hyperintense ulnar nerve could be a useful predictive factor for UNE.

MRI features of symptomatic amputation neuromas.

OBJECTIVES: To demonstrate the magnetic resonance imaging (MRI) features of amputation neuromas in lower extremity amputees and investigate independent predictive MRI features for symptomatic neuromas. METHODS: This retrospective study included 45 amputation neuromas in 44 lower extremity amputees. Two radiologists assessed the imaging features, including shape, size, type (end-bulb or spindle), signal intensity (SI), heterogeneity, margins, enlarged fascicles, dark outer rim, tail sign, target sign, enhancement, perilesional fibrosis, and muscle denervation. The neuromas were categorized into symptomatic (n = 24) or asymptomatic (n = 21). Symptomatic neuromas were determined based on neuropathic pain characteristics, the presence of Tinel's sign or tenderness, and response to local anesthetic injection. Univariate and multivariate analyses were performed to identify independent predictive MRI features. RESULTS: Of 45 neuromas, 80% (36/45) were end-bulb neuromas and 20% (9/45) were spindle-type neuromas. Eighty percent of the neuromas (36/45) were heterogeneous on T2-weighted images (WIs). Enlarged fascicles were present in 42% (19/45) and dark outer rims in 27% (12/45) of the neuromas. Among the 23 neuromas with enhanced images, 78% (18/23) showed enhancement. Heterogeneity on T2-WIs and enhancement ratios were significantly different between the asymptomatic and symptomatic neuroma groups (p < 0.05). The multivariate analyses indicated that heterogeneity on T2-WIs was an independent factor associated with symptomatic neuromas (p < 0.001). CONCLUSIONS: Heterogeneity on T2-WIs could be a predictive indicator for symptomatic neuromas in lower extremity amputees. KEY POINTS: • Amputation neuromas are classified as either end-bulb or spindle-type. They can show enlarged fascicles, dark outer rims, and enhancement. • Heterogeneity on T2-weighted images could be a predictive indicator for symptomatic neuromas. • Predicting the symptomatic neuroma on MRI would help in effective management of stump pain.

Analysis of Fracture Characteristic and Medial Collateral Ligament Injury Relationships in Terrible Triad Elbow Injuries.

PURPOSE: The objectives of this study were to identify the relationship between fracture characteristics and medial collateral ligament (MCL) injuries in terrible triad injuries of the elbow. METHODS: Between 2010 and 2018, 60 patients who underwent surgery for terrible triad elbow injuries were retrospectively reviewed. Using magnetic resonance imaging (MRI) assessments, patients were stratified into those who had intact or low-grade partial MCL tears (low-grade MRI-MCL group) and those who had high-grade partial or full-thickness MCL tears (high-grade MRI-MCL group). We also analyzed patients according to whether they underwent MCL repair surgery. Fractures of the radial head were assessed according to Mason's classification system and measurements of fracture fragment arc on axial cuts. Fractures of the coronoid processes were assessed according to the system of Regan and Morrey and measurements of coronoid process volumes. RESULTS: Patients in the high-grade MRI-MCL group (28 patients) had a more comminuted and higher fragment arc of radial head fractures than those in the low-grade MRI-MCL group (32 patients) (143º ± 45º vs 119º ± 31º). However, the volume of coronoid fracture fragments was smaller in the high-grade MRI-MCL than in the low-grade MRI-MCL group (359 ± 325 mm3 vs 722 ± 448 mm3). The MCL repair group (22 patients) also had a more comminuted and higher fragment arc in radial head fractures (153º ± 44º vs 117º ± 31º) and a smaller coronoid process fracture volume (236 ± 224 mm3 vs 735 ± 419 mm3) than the non-MCL repair group (38 patients). CONCLUSIONS: Our results demonstrated that high-grade MCL injuries are associated with comminuted and larger-sized radial head fractures, as well as smaller-sized coronoid process fractures in terrible triad injuries. In making a decision regarding surgical treatment, these fracture characteristics could help to predict the severity for MCL injury in terrible triad injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Threshold-based quantification of fatty degeneration in the supraspinatus muscle on MRI as an alternative method to Goutallier classification and single-voxel MR spectroscopy.

BACKGROUND: Conventional fat quantification methods for rotator cuff muscles have various limitations, such as inconsistent reliabilities of the Goutallier grades and need for advanced techniques in quantitative MRI sequences. We aimed to examine a threshold-based fat quantification method in the supraspinatus muscle on standard T1-weighted MR images and compare the threshold-based method with Goutallier grades and MR spectroscopy. METHODS: We retrospectively examined 38 symptomatic patients, who underwent T1 and T2-weighted fast spin-echo MR imaging and a single voxel spin-echo MR spectroscopy. The supraspinatus muscle and fossa were manually segmented in T1-weighted sagittal images and clustering-based thresholding was applied to quantify the fat fractions in the segmented areas using custom MATLAB software. Threshold-based fat fractions were compared with the Goutallier grades and MR spectroscopy fat/water ratios. A one-way analysis of variance and Pearson correlation were tested in the MATLAB software. RESULTS: Inter-observer reliability of threshold-based fat fractions for the supraspinatus muscle and fossa were 0.977 and 0.990 respectively, whereas the reliability of the Goutallier grading was 0.798. Threshold-based fat fractions in the supraspinatus fossa were significantly different between various Goutallier grades (one-way ANOVA, p < 0.001). Threshold-based fat fractions in the supraspinatus muscle strongly correlated with the MR spectroscopy fat/water ratio (Pearson correlation R-square = 0.83). CONCLUSIONS: Threshold-based fat quantification on standard T1-weighted MR images was highly reliable and produced comparable results to conventional Goutallier grades and MR spectroscopy fat/water ratios and could serve as an alternative method for accurate fat quantification in rotator cuff muscles.

Acetabular Ossicles: Epidemiology and Correlation With Femoroacetabular Impingement.

PURPOSE: To investigate (1) the prevalence, size, and location of acetabular ossicles in general population; (2) differentiation between the characteristic types of acetabular ossicles: unfused ossification centers (true os acetabuli), rim fractures, labral calcifications and loose bodies; and (3) correlation between acetabular ossicles, and femoroacetabular impingement (FAI) with symptoms. METHODS: Patients aged 16 to 60 years who underwent abdominal and pelvic computed tomography (CT) with non-orthopaedic indications in 2016 and patients who underwent hip arthroscopy surgery from 2010 to 2016 in our institution were included for asymptomatic and symptomatic groups, respectively. Two investigators evaluated CT images to find the prevalence, size, location of acetabular ossicles, and relationship with symptoms and FAI. We correlated them with types of ossicles. RESULTS: This study included 5684 patients with 11368 hips (2790 male and 2894 female; mean age, 44.3 years) for asymptomatic group, and 264 patients with 289 hips (171 male and 93 female; mean age, 34.4 years) for symptomatic group. The prevalence of ossicles in symptomatic and asymptomatic groups was 8.65% (25/289) and 3.33% (378/11,368), respectively. The distribution of ossicles types in general population were labral calcifications (55.09%), rim fractures (35.73%), unfused ossification center (1.24%), and loose bodies (7.94%). Labral calcification had the smallest size and mostly was asymptomatic. Rim fracture was correlated with FAI in general (83.33%; P < .001) but not with any types of FAI. Size of ossicles was related with symptom (895.28 vs 103.64 mm3; P < .001). CONCLUSIONS: The prevalence of acetabular ossicles in general population are 3.46%, with significantly higher prevalence of acetabular ossicles were found in symptomatic group (8.65% vs 3.33%). Size of acetabular ossicles was significantly associated with hip pain. Labral calcification was the most common type of acetabular ossicles. Significant relationship was found between rim fracture and FAI but not with any specific types of FAI. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Location and Correlation of Acetabular Labral Tears and Paralabral Cysts Using Magnetic Resonance Imaging or Magnetic Resonance Arthrography in Patients With Femoroacetabular Impingement.

PURPOSE: To evaluate the prevalence and location of paralabral cysts and the correlation between the type of femoroacetabular impingement (FAI) and acetabular labral tears, as well as the location of the paralabral cysts. METHODS: Patients who received a diagnosis of FAI syndrome using plain radiography, magnetic resonance imaging or magnetic resonance arthrography, or computed tomographic arthrography from 2010 to 2015 were included in this study. The exclusion criteria were patients with arthritis (Tönnis grade 2 or greater) or dysplasia. We identified paralabral cysts and their location, size, configuration. Correlations between the type of FAI and labral tears and paralabral cysts were analyzed using the χ-square test. RESULTS: Among 506 patients with FAI, paralabral cysts were found in 51 patients (55 hips) and were located anterosuperiorly in 40% of cases, posterosuperiorly in 36%, anteroinferiorly in 17%, and posteroinferiorly in 8%. We identified multilocular cysts in 60% of hips and unilocular cysts in 40%. Labral tears were radiographically found in 44 of 55 hips with paralabral cysts (80%); they were located anterosuperiorly in 59% and posterosuperiorly in 41%. Although paralabral cysts were found in the anteroinferior and posteroinferior areas, acetabular labral tears were not identified in the anteroinferior and posteroinferior areas. Classification of the type of FAI showed cam type in 14 of 55 hips (25.5%), pincer type in 16 (29%), mixed type in 7 (13%), labral tears in 15 (27%), and normal findings in 3 (5.5%). No correlation was found between the type of FAI and labral tears (P = .739) or the location of paralabral cysts (P = .228). CONCLUSIONS: Paralabral cysts in patients with FAI most commonly are found in the anterosuperior area and are of the multilocular type. Although paralabral cysts in the anterosuperior and posterosuperior portions are related to labral tears, those in the anteroinferior and posteroinferior portions are not. LEVEL OF EVIDENCE: Level IV, diagnostic case series.

Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre.

OBJECTIVES: To analyse the incidence and type of epidural steroid injection (ESI)-related adverse events, including procedure-related complications and drug-related systemic effects requiring hospitalisation or emergency room (ER) visits. METHODS: This study included 52,935 ESI procedures performed in 22,059 patients in our department from March 2004 to February 2016. Of these, we retrospectively reviewed the cases of 1570 patients (1713 procedures) who were hospitalised or visited the ER within 1 month after ESI. ESI-related events were classified as procedure-related complications, drug-related systemic effects, or of uncertain relationship. Descriptive data are provided; no statistical analysis was performed. RESULTS: There were 244 ESI-related events in 235 patients (males:females = 102:133; mean age: 65.7 years; range: 20-93 years). The incidence of ESI-related events was 0.46% per procedure, including 14 procedure-related complications, 56 drug-related systemic effects, and 174 events of uncertain cause. Of the 52,935 patients, 6 (0.011%) experienced major complications (two spine haematomas and four infections), 1 patient died, and 1 experienced neurological sequelae. CONCLUSIONS: Although major procedure-related complications and drug-related systemic effects of ESI requiring hospitalisation are very rare, infection and haematoma can occur, resulting in serious outcomes. Hence, ESI should be carefully considered in high-risk patients. KEY POINTS: • The incidence of ESI-related events requiring hospitalisation was 0.46%. • The incidence of procedure-related complications was 0.026%. • The incidence of drug-related systemic effects was 0.11%. • The incidence of major complication of ESI was 0.011%. • The major complications were spine infection, haematoma, and sepsis.

A prospective randomized study comparing three different approaches to fluoroscopy-guided shoulder arthrography according to the experience of practitioners.

OBJECTIVE: To compare three approaches via the anterior and posterior glenohumeral joints, and the rotator interval in fluoroscopy-guided shoulder arthrography according to the experience of the practitioners. MATERIALS AND METHODS: This prospective randomized study was originally designed to have 34 subjects for each approach, and finally evaluated 98 patients (mean age: 51.5 years; 55 men) from July to December 2014, who had shoulder arthrography via the anterior (n = 41) or posterior glenohumeral joint (n = 27) approaches, or via the rotator interval approach (n = 30) by residents (n=76) or fellows (n=22). The success rate, number of punctures, fluoroscopy time, radiation dose, and complications of the three methods were compared, and according to the practitioners. RESULTS: The success rate was 100% for the anterior glenohumeral joint approach (34 out of 34), 90.0% for the posterior glenohumeral joint approach (23 out of 30), and 88.2% for the rotator interval approach (30 out of 34; p = 0.013). There was no difference in the success rate according to the practitioners' experience. Fluoroscopy time was longest for the posterior glenohumeral joint approach (mean: 95.44 s) and shortest for the rotator interval approach (mean: 31.57 s, p = 0.006). Radiation dose was larger by 1st- or 2nd-year residents (p = 0.014), with no difference among the three approaches. Only one patient who underwent arthrography using the posterior glenohumeral joint approach complained about post-procedural pain. CONCLUSION: Fluoroscopy-guided shoulder arthrography via the posterior glenohumeral joint or rotator interval approach may be difficult for trainees, and the posterior glenohumeral joint approach may need a long fluoroscopy time.

Morphologic Changes and Outcomes After Arthroscopic Acetabular Labral Repair Evaluated Using Postoperative Computed Tomography Arthrography.

PURPOSE: To investigate smaller sized labra after acetabular labral repair comparing preoperative and postoperative computed tomography arthrography (CTA) and to assess the correlation between the anatomic changes and clinical outcomes. METHODS: The design and protocol of this retrospective study were approved by the institutional review board of our hospital. The inclusion criteria included age older than 18 years and hip pain associated with mechanical symptoms. Patients with previous hip surgery, avascular necrosis, rheumatologic disorders, or advanced arthritis were excluded. All tears with femoroacetabular impingement were treated with bumpectomy or acetabuloplasty and repaired using arthroscopic suture anchors. We evaluated clinical outcomes using the modified Harris Hip Score (mHHS) and the morphologic changes and radiologic outcomes (labral retear and leakage of dye) using CTA at a minimum 2-year follow-up. The paired t test was performed to detect changes in labral height, labral width, and mHHS. RESULTS: Forty labral tears in 40 patients (mean age, 32.1 ± 9.2 years) underwent labral repair, with femoroplasty in 20 hips and acetabuloplasty in 17 hips, and no patients required capsular repair after capsulotomy. No leakage of contrast dye was detected during the follow-up CTA procedure. No labral retears were observed after labral refixation at the postoperative CTA evaluation. However, the mean width and height of the labrum changed from 8.1 mm and 4.9 mm, respectively, preoperatively to 6.7 mm and 4.4 mm, respectively, at the postoperative follow-up (decreasing by 19% and 11%, respectively; both P < .001). In addition, the mean mHHS for the 36 patients in the complete repair group improved from 61 ± 16.0 to 90 ± 9.6 (P = .01). Four hips showed incomplete repairs. CONCLUSIONS: Repaired labra are well maintained after capsulotomy based on follow-up CTA after arthroscopic labral repair. In addition, decreased height and width of the labra do not affect the clinical outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic study (case series [no, or historical, control group]).

An Osteochondral Lesion of the Distal Tibia and Fibula in Patients With an Osteochondral Lesion of the Talus on MRI: Prevalence, Location, and Concomitant Ligament and Tendon Injuries.

OBJECTIVE: The purpose of this study was to evaluate the prevalence and common location of a coexisting osteochondral lesion of the distal tibia and fibula and of associated abnormalities of the ankle ligaments and tendons on MRI in patients with an osteochondral lesion of the talus (OLT). MATERIALS AND METHODS: A search of a database of MRI studies performed between July 2003 and January 2014 yielded MRI examinations of 297 feet with OLTs. Two readers reviewed the MRI examinations independently for the presence of an osteochondral lesion of the distal tibia and fibula and for concomitant ligament and tendon injuries. If an osteochondral lesion of the distal tibia and fibula was present, the reviewers also recorded the location (zones 1-10) and stage. Interobserver and intraobserver reliabilities were assessed using kappa statistics. The associations between a coexisting osteochondral lesion of the distal tibia and fibula and an OLT or a concomitant ankle injury were evaluated using the chi-square test. RESULTS: Readers A and B identified 61 (20.5%) and 47 (15.8%) coexisting osteochondral lesions of the distal tibia and fibula, respectively, with good interobserver (κ = 0.73) and excellent intraobserver (κ = 0.97) reliabilities. The most common location of a coexisting osteochondral lesion of the distal tibia and fibula was zone 4 (29.5%) by reader A and zone 2 (21.3%) by reader B. Stage I and stage IIA were common (> 85%). The frequency of osteochondral lesions of the distal tibia and fibula was not significantly different according to the location or stage of OLT. Abnormalities in the tibialis posterior tendon and in the anterior and posterior talofibular, calcaneofibular, and deltoid ligaments were significantly more common in patients with a coexisting osteochondral lesion of the distal tibia and fibula than in those with an isolated OLT (p < 0.05). CONCLUSION: A coexisting osteochondral lesion of the distal tibia and fibula is not rare on MRI in patients with an OLT and is related to a higher frequency of concomitant ankle ligament and tendon injuries.

Acute benign vertebral compression fractures: "see-through sign" on contrast-enhanced MR images.

PURPOSE: To retrospectively evaluate the diagnostic role of the contrast-enhanced MRI (CE-MRI) for differentiation between benign VCFs and malignant VCFs focusing on the internal transparent trabecular bone on CE-MRI (the "see-through sign"). MATERIALS AND METHODS: The institutional review board approved this study and informed consent was waived due to the retrospective nature of the study. From January 2012 to December 2013, all 149 consecutive benign or malignant VCF patients were enrolled for consideration in this study from a CE-MRI database. In the first analysis, four radiologists independently evaluated the presence or absence of the see-through sign. The see-through sign was defined as internal transparent trabecular bone morphology on CE-MRI. The intraclass correlation coefficient (ICC), percentage agreement, and Fleiss's kappa statistics were obtained. RESULTS: Fifty-seven patients (M:F = 27:30; mean age, 63 years; age range, 20-88 years) who diagnosed as acute benign (n = 24) and malignant (n = 33) VCFs were finally included for the analysis. The results of all readers showed that the see-through sign was associated with acute benign VCFs (p < 0.05). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of the see-through sign ranged from 75-96, 70-88, 66-85, 81-97 %, respectively. The inter-observer reliability of the see-through sign was sufficient with ICC = 0.847, percentage agreement = 78.9, and κ = 0.578. CONCLUSION: The see-through sign on CE-MRI is featured in acute benign VCFs, and it can be a useful finding to differentiate between benign and malignant VCFs.

Intra-Articular Injections in Patients with Femoroacetabular Impingement: a Prospective, Randomized, Double-blind, Cross-over Study.

We evaluated and compared the effectiveness of intra-articular injection of hip joint using hyaluronic acid and steroid in patients with femoroacetabular impingement (FAI). Thirty patients with FAI clinically and radiologically were enrolled and underwent hip injection using steroid (TA) or hyaluronic acid (HA) at 0-weeks with cross-over injection at 2-weeks in patients without clinical response of decrease of pain intensity less than 2-point. Patients were followed up to 12-weeks for pain intensity (Numeric rating scale, NRS: 0-10), hip disability score (HOOS), oral medication and adverse events. In 17 patients without cross-over, HOOS at 2-weeks was improved significantly in patients with HA injection (mean increase of HOOS = 13.8 with HA vs. -2.2 with TA, P = 0.031) without difference of NRS (P = 0.943). In 13 patients with cross-over, NRS was significantly improved at 2-weeks with first TA injection (mean decrease of NRS= 1.7 with first TA vs. 0.3 with first HA, P = 0.036), without difference of HOOS (P = 0.431). At 4-weeks, NRS and HOOS were significantly different according to injection drugs (NRS: 0.9 with TA first and HA later vs. 2.7 with HA first and TA later, P = 0.001; mean increase of HOOS: 5.3 with TA first and HA later vs. 10.2 with HA first and TA later, P = 0.032). Intra-articular hip injection may be effective in FAI, with faster effect of pain improvement by TA and more delayed effect of function improvement by HA.

Measurement of Coracohumeral Distance in 3 Shoulder Positions Using Dynamic Ultrasonography: Correlation With Subscapularis Tear.

PURPOSE: To detect differences between the values of dynamic coracohumeral distance (CHD) measured using ultrasonography (USG) in different shoulder rotations and to investigate its correlation with subscapularis tear. METHODS: We prospectively enrolled consecutive patients (n = 168) who were scheduled to have arthroscopic rotator cuff repair. Patients with a history of previous shoulder surgery or shoulder fracture and patients with external rotation less than 30° were excluded from the study. Dynamic CHD was measured using USG in 3 different shoulder positions: external rotation, neutral and internal rotation. We evaluated the intrarater reliability with 3 times repetition of measurement. Patients were divided into 1 of 3 groups according to arthroscopic findings: intact subscapularis, partial-thickness tear, and full-thickness tear of the subscapularis. The control group (n = 23) included patients without rotator cuff tears from the outpatient clinic. Subgroup analysis-according to the presence of dynamic subcoracoid stenosis, defined as a CHD less than 6 mm measured in internal rotation-was performed to find the clinical effect of dynamic subcoracoid stenosis. RESULTS: A partial-thickness tear of the subscapularis tendon was present in 60 patients (35.7%) and a full-thickness tear in 26 patients (15.4%) among 168 patients. The CHD was maximum in external rotation and the narrowest in internal rotation. There were no statistical differences in the CHDs between groups with different subscapularis tear status. According to the presence of dynamic subcoracoid stenosis, patients with dynamic subcoracoid stenosis had a significantly higher incidence of partial-thickness subscapularis tear than those without stenosis (P = .022). CONCLUSIONS: The CHD values were narrowest in shoulder internal rotation, which is thought to be the pathogenic position. We could not confirm the correlation between CHD and subscapularis tear. However, patients who have dynamic subcoracoid stenosis had significantly higher incidence of subscapularis tear than others without dynamic stenosis. LEVEL OF EVIDENCE: Level II, prospective prognostic cohort study.

MR Classification System Based on Axial Images for Cervical Compressive Myelopathy.

PURPOSE: To propose a new magnetic resonance (MR) classification system based on axial images for cervical compressive myelopathy (CCM) (Ax-CCM system), to assess the interobserver agreement with the Ax-CCM system, and to evaluate the relationship between Ax-CCM patterns and the baseline severity of CCM and the subsequent surgical outcome. MATERIALS AND METHODS: The institutional review board approved this retrospective study. A total of 202 patients (male-to-female ratio, 128:84; mean age ± standard deviation, 56.3 years ± 11.9; age range, 24-83 years) with CCM who underwent preoperative MR imaging and decompression surgery were retrospectively evaluated. The Ax-CCM pattern was based on the margin and extent of intramedullary hyperintensity on axial T2-weighted images, as follows; type 0 = normal, type 1 = diffuse, type 2 = fuzzy focal, and type 3 = discrete focal. Interobserver variability was analyzed by using the intraclass correlation coefficient across three readers. The modified Japanese Orthopedic Association (JOA) score and the postoperative improvement (good vs little improvement) were evaluated according to the Ax-CCM pattern by using one-way analysis of variance, the χ(2) test, and the Fisher exact test. RESULTS: The intraclass correlation coefficient for the Ax-CCM system was 0.83. The preoperative JOA score was significantly different according to Ax-CCM pattern across all readers (P < .05), with the type 2 pattern showing the worst preoperative JOA score (mean, 11.6 ± 3.1 for readers A and C and 11.7 ± 2.9 for reader B). The proportion of good improvement was significantly lower with the type 2 pattern (27 of 72 patients, 37%) than with the other patterns (64 of 123 patients, 52%) (P = .034). CONCLUSION: The Ax-CCM system showed good interobserver agreement, and the type 2 pattern was correlated with poor preoperative neurologic status and less postoperative improvement.

Herniation of cartilaginous endplates in the lumbar spine: MRI findings.

OBJECTIVE: The purpose of this study was to determine reliable MRI findings suggesting disk herniation with cartilage endplate herniation in the lumbar spine. MATERIALS AND METHODS: The records of 73 patients who underwent lumbar spinal MRI and lumbar microdiskectomy between March 2005 and January 2009 were searched to find those with the diagnosis of disk herniation with cartilage endplate herniation confirmed during surgery. The following morphologic features were assessed: posterior corners (posterior marginal nodes, dorsal corner defects, Modic changes, and posterior osteophytes), mid endplates (endplate irregularities, Modic changes), and heterogeneous low signal intensity of extruded material. The chi-square test and multiple logistic regression analysis with age, body mass index, and sex as covariates were used for the analysis. The ROC curve was obtained with scores of the statistically significant MRI findings. RESULTS: Posterior marginal nodes, posterior osteophytes, Modic changes in posterior corners, mid endplate irregularities, Modic changes in mid endplates, and heterogeneous low signal intensity of extruded material were significantly more frequent in patients with disk herniation with cartilage endplate herniation (0.000 < p < 0.009). The AUC for diagnosing disk herniation with cartilage endplate herniation with our scoring system of the six MRI findings (0-6) was 0.888. CONCLUSION: The presence of disk herniation with cartilage endplate herniation could be ascertained with the following MRI findings: posterior marginal nodes, posterior osteophytes, mid endplate irregularities, heterogeneous low signal intensity of extruded material, and Modic changes in posterior corners and mid endplates.

Fluoroscopic cervical paramidline interlaminar epidural steroid injections for cervical radiculopathy: effectiveness and outcome predictors.

OBJECTIVE: The purpose of this study is to analyze the effectiveness of fluoroscopic cervical paramidline interlaminar epidural steroid injection (ESI) as well as to assess outcome predictors. METHODS: One hundred forty-three patients (M:F = 89:54, mean age = 53.1 years old) who received cervical paramidline interlaminar ESIs in 2011 were included in this study. Initial improvements at 2 weeks were assessed. For possible outcome predictors, clinical and MR variables were statistically analyzed using the Mann-Whitney U, Chi-square, and Fisher's exact tests. RESULTS: Initial improvements after cervical paramidline interlaminar ESIs at 2 weeks were reported in 115 of 143 patients (80.8%). Patients with paresthesia only and no pain showed significantly fewer improvements after ESIs (11/19, 57.9%) than patients with pain (104/124, 83.9%) (p = 0.013). Other variables were not statistically significant outcome predictors. CONCLUSIONS: Fluoroscopic paramidline interlaminar cervical ESIs effectively managed cervical radiculopathy, irrespective of the cause or zone of nerve root compression, and patients with paresthesia only experienced fewer improvements.

MR-based outcome predictors of lumbar transforaminal epidural steroid injection for lumbar radiculopathy caused by herniated intervertebral disc.

OBJECTIVES: To evaluate the MR-based outcome predictors of lumbar transforaminal epidural steroid injection (ESI) for lumbar radiculopathy caused by herniated intervertebral disc (HIVD). METHODS: A total of 149 patients (male/female 75:74; mean age 51.5 years) with the very worst (87 patients) or the very best outcome (62 patients) after ESI were enrolled in this study. They were selected from 1,881 patients who underwent lumbar transforaminal ESI for lumbar radiculopathy caused by HIVD from January 2007 to December 2008. Two radiologists reviewed MR in consensus. Chi-square test and Fisher's exact test were used to evaluate the difference between the two groups. RESULTS: HIVD in the foraminal-extraforaminal zone were significantly more common in the very best outcome group (16/24, 66.6 %) than HIVD in the central-subarticular zone (46/125, 36.8 %) (P = 0.012). Other factors such as HIVD zone, T2-high signal, relation to nerve root, corner change, Modic change, disc height loss, grade of disc degeneration, and osteophyte were not statistically significant. CONCLUSION: HIVD in the foraminal or extraforaminal zone is the only good MR-based outcome predictor of lumbar transforamial ESI for lumbar radiculopathy.