CT-based comprehensive scoring system for assessing hip arthropathy in ankylosing spondylitis: feasibility study with clinical correlation.

OBJECTIVE: To develop a CT-based scoring system for assessment of hip arthropathy in AS. METHODS: All AS patients were prospectively recruited, consented, and underwent whole-body stereoradiographs and pelvis CT, which were assessed by two independent radiologists. Stereoradiographs were assessed according to Kellgreen-Lawrence and BASRI-h. For the Hip arthropathy CT score in AS (HACTSAS), joints were divided into 7 segments and scored for joint space, osteophytes, subchondral cysts/erosions. Patients were clinically assessed for range of motion (ROM), pain, and clinical scores (BASMI, BASFI, ASQol, BASDAI and ASDAS). Radiological scores correlations with clinical parameters were compared. ROM sensitivity and specificity for hip arthropathy (BASRI-h ≥ 2) were calculated. RESULTS: Sample included 112 patients, with 36/112 females and 76/112 males. Average age was 51.0 ± 11.2 years and mean duration of AS was 20.9 ± 9.6 years. ICC for HACTSAS, Kellgreen-Lawrence and BASRI-h were 0.89, 0.89 and 0.82 respectively. HACTSAS showed moderate absolute correlation with ROM (ρ=-0.41) and BASMI (ρ = 0.45), and weak with pain (ρ = 0.18) and BASFI (ρ = 0.25). BASRI-h and Kellgreen-Lawrence exhibited moderate correlation with ROM (ρ=-0.44 and ρ=-0.40, respectively), weak with pain (ρ=-.27and ρ=-0.23, respectively) and BASFI (ρ=-0.16 and ρ=-0.18, respectively), but only weak with BASMI (ρ=-0.34 and ρ=-0.36, respectively). Internal rotation <15°, abduction <31°, and intermalleolar distance <75cm were, respectively, 73%, 70% and 73% sensitivity and 81%, 65% and 68% specific for hip arthropathy. CONCLUSION: HACTSAS exhibited higher correlation with BASMI and BASFI when compared with BASRI-h, but less correlation with pain and ROM. Internal rotation was the best clinical discriminator for hip arthropathy.

Meniscal Root Tears: An Update Focused on Preoperative and Postoperative MRI Findings.

Meniscal root tears represent radial tears or avulsions of the meniscal cartilage at the tibial attachment site that profoundly affect meniscal biomechanics and kinematics. Meniscal root tears have the functional effect of a total meniscectomy and can lead to rapid degenerative change with development of early knee osteoarthritis (OA). A growing range of arthroscopic surgical techniques have been developed to repair meniscal root tears with the aim of restoring joint kinematics and contact pressures and delaying the development of OA. With increased understanding of the anatomy and biomechanics of the meniscal root, meniscal root injury repair has become the treatment of choice in knees with nonadvanced OA. This article reviews the anatomy and biomechanics of the meniscal roots, clinical and imaging diagnostic criteria of meniscal root tears, correlation between arthroscopy and MRI in the diagnosis and classification of meniscal root tears, and expected and abnormal MRI findings after meniscal root repair. Familiarity with MRI signs and classifications of meniscal root tears, as well as with root repair surgical techniques, can aid radiologists in correctly reporting preoperative and postoperative MRI findings.

Multimodality Imaging of Foreign Bodies: New Insights into Old Challenges.

Traumatic wounds and lacerations are a common reason for patients to present to emergency departments, with retained foreign bodies (FBs) accounting for 7%-15% of cases, particularly those involving the extremities. These retained materials result in a granulomatous tissue response known as an FB reaction, a pathologic attempt to isolate the FB from the host. The most common FB materials are glass, metal, and wood, but other compositions can also be found, such as plastic and animal-derived materials. Clinical history, physical examination, and wound exploration are essential in investigation of retained material but are not sufficient to exclude an FB, and additional investigation is required. Imaging evaluation is a useful tool to help depict and locate an FB, assess possible complications, and guide removal. Conventional radiography, the first-line method in this scenario, is a widely available low-cost depiction method that has good sensitivity for depicting FBs. If the retained material is not depicted at conventional radiography, US can be performed. US is highly sensitive in depicting both radiolucent and radiopaque FBs in superficial locations. For deeper objects, CT may be necessary. MRI is the best imaging modality to delineate local soft-tissue and osseous complications. Retained FBs can result in early and delayed complications, with infection being the most frequent complication. To avoid preventable morbidities related to FBs, radiologists should be familiar with imaging findings and provide essential information to help the attending physician treat each patient. Online supplemental material is available for this article. ©RSNA, 2020.

Whole-Body Imaging of Multiple Myeloma: Diagnostic Criteria.

Multiple myeloma (MM) is a clonal plasma cell proliferative disorder characterized by primary infiltration of bone marrow and excessive production of abnormal immunoglobulin. This disease is the second most common hematologic malignancy (after lymphoma), and its spectrum of characteristic features are widely known by the acronym CRAB (hypercalcemia, renal impairment, anemia, and bone lesions). Traditionally, the diagnosis and treatment of MM have been triggered by clear end-organ damage. However, owing to recently introduced treatment options that can extend patient survival and the increasing recognition of biomarkers that can be used to identify patients at high risk of progression to active disease, the diagnostic criteria have been revised. Bone disease is one of the most prominent features of MM, and imaging has an important role in diagnosis and follow-up, with each whole-body imaging modality having different indications in distinct disease situations. Skeletal survey has been the standard imaging procedure used during the past decade, but it should no longer be used unless it is the only option. Whole-body low-dose CT is a reasonable and cost-effective initial imaging approach. Whole-body MRI is the most sensitive technique for detecting bone involvement and assessing painful complications. PET/CT is the best tool for evaluating treatment response. The importance of radiologists has increased in this scenario. Therefore, to properly assist hematologists and improve the care of patients with MM, it is essential that radiologists know the updated diagnostic criteria for MM, indications for and limitations of each imaging option, and recommendations for follow-up. Online supplemental material is available for this article. ©RSNA, 2019.

Study on the anatomic relationship between the clavicle and the coracoid process using computed tomography scans of the shoulder.

BACKGROUND: The current trend in the treatment of acromioclavicular dislocations is to reconstruct the coracoclavicular ligaments by using transosseous tunnels in the coracoid process or in the clavicle, yet there is no definition as to the location of these. To study the anatomic relationship between the coracoid process and the clavicle, we made measurements to find a convergence point (cP) between them that has intraoperative applicability for creating transosseous tunnels. METHODS: We analyzed 74 computed tomography scans (40 female and 34 male patients). Measurements were taken in the axial and sagittal planes and obtained from a cP, as determined by the intersection of the cortical surface of the clavicle and the coracoid process, with various relationships having been established. RESULTS: On average, the cP was determined to be about 2.9 cm and 2.5 cm distant from the coracoid process apex for male and female patients, respectively, whereas the width at this position was determined to be 2.1 cm and 1.9 cm. In the clavicle, this point is on average 2.9 cm and 2.5 cm distant from the acromioclavicular joint in male and female patients, respectively, and its anteroposterior width at this point is on average 1.9 cm and 1.6 cm. CONCLUSION: The cP of the clavicle and the coracoid process was determined with the aim of preparing bone tunnels in operations for treating acromioclavicular dislocations.

Relationship between spinal structural damage and sagittal balance in axial spondyloarthritis: Is the thoracic spine the starting point?

OBJECTIVES: To assess the relationship between spinal structural damage, sagittal balance parameters and spine curvatures in patients with axial spondyloarthritis (axSpA). MATERIAL AND METHODS: In this cross-sectional study, the pelvic and sagittal balance parameters were obtained through EOS® (Biospace, Paris, France). Patients were divided into three groups according to the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) tertiles (G1 ≤6, n = 36; G2: 6.1-31, n = 36; G3 >31, n = 35) and pelvic and sagittal parameters were compared across them. Multivariable regression analysis was performed to analyze the impact of spinal structural damage and of other factors on sagittal vertical axis (SVA), an important sagittal balance parameter. RESULTS: A total of 107 patients was included. G2 and 3 exhibited higher mean values of thoracic kyphosis T1-T12 when compared to G1 (10.5°(12.3) vs. 22.3°(17.3) vs. 35.2°(14.6), p < 0.001), and G3 demonstrated lumbar L1-S1 straightening compared to the other groups (55.7°(9) and 50.7°(19.8), G1 and G2, respectively, vs. 35.7°(13.2), p < 0.001). Mean SVA values showed an increasing gradient from G1 to G3 (21.6(25.1) vs. 41(44.3) vs. 84.3(47.2)mm, p < 0.001). In the multivariable regression, a one-unit increase in total mSASSS was associated with an average 0.8 mm higher SVA. CONCLUSIONS: Our data showed that more spinal structural damage is associated with a higher SVA, reflecting poorer sagittal balance. Patients with increasing spinal damage have an important increase in thoracic kyphosis suggesting that postural modifications in patients with axSpA might have their origin in the thoracic spine.

Whole-Body MRI in Musculoskeletal Oncology: A Comprehensive Review with Recommendations.

Whole-body (WB) MRI has emerged as an attractive method for oncologic evaluation, potentially replacing conventional imaging modalities and providing a one-step wide-coverage assessment of both the skeleton and soft tissues. In addition to providing anatomic information, WB MRI may also yield a functional analysis with the inclusion of diffusion-weighted imaging (DWI). DWI translates microstructural changes, resulting in an excellent alternative to fluorodeoxyglucose PET/CT. WB MRI (with DWI) offers comparable accuracy to PET/CT and has the advantage of avoiding ionizing radiation. Technological advances and the development of faster protocols have prompted greater accessibility of WB MRI, with growing applications in routine practice for the diagnosis, staging, and follow-up of cancer. This review discusses the technical considerations, clinical applications, and accuracy of WB MRI in musculoskeletal oncology. Keywords: Pediatrics, MR Imaging, Skeletal-Axial, Skeletal-Appendicular, Soft Tissues/Skin, Bone Marrow, Extremities, Oncology, Musculoskeletal Imaging © RSNA, 2023.

Osteoid osteoma: the great mimicker.

Osteoid osteoma is a painful, benign and common bone tumor that is prevalent in young adults. The typical clinical presentation consists of pain that becomes worse at night and is relieved by nonsteroidal anti-inflammatory drugs. The most common imaging finding is a lytic lesion, known as a nidus, with variable intralesional mineralization, accompanied by bone sclerosis, cortical thickening and surrounding bone marrow edema, as well as marked enhancement with intravenous contrast injection. When the lesion is located in typical locations (intracortical bone and the diaphyses of long bones), both characteristic clinical and radiological features are diagnostic. However, osteoid osteoma is a multifaceted pathology that can have unusual presentations, such as intraarticular osteoid osteoma, epiphyseal location, lesions at the extremities and multicentric nidi, and frequently present atypical clinical and radiological manifestations. In addition, many conditions may mimic osteoid osteoma and vice versa, leading to misdiagnosis. Therefore, it is essential to understand these musculoskeletal diseases and their imaging findings to increase diagnostic accuracy, enable early treatment and prevent poor prognosis.

Accessory head of biceps brachii muscle: anatomy, histology, and MRI in cadavers.

OBJECTIVE: The purpose of our study is to describe and define an anatomic variation located close to the bicipital groove using MRI with gross anatomic and histologic correlation in cadavers. MATERIALS AND METHODS: Ten fresh male human shoulders were harvested and used in this investigation. They were derived from persons with a mean age of death of 78.9 years (age range, 58-92 years). MR arthrography using proton density-weighted sequences was used to obtain images in axial, coronal, and sagittal planes. After imaging, the specimens were cut in axial, coronal, and sagittal sections using a band saw. The slices were then photographed to allow correlation with the MR arthrographic images, followed by histologic analysis. RESULTS: Two anomalous tendons, both intimate with the tendon of the long head of the biceps brachii muscle in the bicipital groove, were recognized. The origin of both tendons was in the greater tuberosity near the articular capsule. These structures had a muscular belly that was joined with the other biceps bellies. At the level of the bicipital groove, the anomalous tendons appeared as hypointense structures in proton density-weighted images, with a mostly flat morphology in axial and coronal planes. The average dimensions of these structures were 45.5 (craniocaudal)x6.2 (anteroposterior)x0.85 (mediolateral) mm. CONCLUSION: The MR images, gross anatomic inspection, and histologic information led us to conclude that these anomalous structures were accessory heads of the biceps brachii muscle.

Morphology of the distal radioulnar joint: cadaveric study with MRI and MR arthrography with the forearm in neutral position, pronation, and supination.

OBJECTIVE: The purpose of this study was to evaluate the physiologic extent and thickness of the cartilage and bare areas of the distal radioulnar joint with gross anatomic examination, MRI, and MR arthrography with the forearm in neutral position, maximal pronation, and maximal supination. MATERIALS AND METHODS: MRI and MR arthrography were performed on 10 cadaveric specimens (mean age at death, 82.9 years; range, 56-97 years) with the forearm in neutral position, maximal pronation, and maximal supination. Cartilage surface and thickness were assessed, and degenerative changes and bare areas were evaluated in consensus by two musculoskeletal radiologists. Gross anatomic and histologic examinations were used as the reference standard. RESULTS: MRI in maximal pronation and supination was helpful in evaluation of the ulnar cartilage. In the axial plane, any change in cartilage thickness in the ulnar head was related to chondral degeneration. In the coronal plane, cartilage thickness proved to be an unreliable sign in the assessment of chondral degeneration. The presence of osteophytes in the proximal aspect of the joint was easily detected and proved to be a reliable criterion for joint degeneration. Bare areas were found at the proximal and volar attachments of the joint capsule. CONCLUSION: Detailed knowledge of the anatomy of the distal radioulnar joint should allow more accurate assessment of degenerative changes and localization of erosions in inflammatory joint disease. Imaging with the forearm in maximal pronation and supination can improve visualization of the cartilage of the ulnar head.

Edematous processes within Kager fat pad: magnetic resonance imaging, gross anatomical, and histological studies in cadavers with clinical correlation.

OBJECTIVE: To demonstrate the anatomical features of Kager fat pad (KFP) and its fasciae using magnetic resonance imaging, gross anatomy, and histology in cadavers; and to correlate the data with image findings in patients. METHODS: The KFP was analyzed in 10 fresh human cadavers and 152 clinical cases. The retrospective clinical study was institutional review board approved. The specimens were studied by magnetic resonance imaging and sectioned for anatomical/histological correlation. Clinical cases were selected to evaluate the frequency, distribution, and patterns of edema/inflammation in KFP. The square of the Pearson product moment correlation coefficient and Student t tests were performed. RESULTS: Fasciae about KFP are double layered and derived from the union of the fascia of the leg and flexor and peroneal retinacula. Edema in KFP could be divided into diffuse, confined anteriorly, confined posteriorly, and confined externally. Confined patterns of edema were associated with paratenonitis and fluid in the Achilles bursae (P < 0.05). CONCLUSIONS: Four patterns of edema occur in KFP. Paratenonitis and bursal fluid were associated with confined edematous patterns. The double layer about KFP may contain edema that affects this region.

Differences between radial and ulnar deviation of the wrist in the study of the intrinsic intercarpal ligaments: magnetic resonance imaging and gross anatomic inspection in cadavers.

OBJECTIVE: To demonstrate how radial and ulnar deviation of the wrist can affect the visualization of the intrinsic intercarpal ligaments using magnetic resonance (MR) imaging, MR arthrography and gross anatomic inspection in cadavers. MATERIALS AND METHODS: The detectability of the intrinsic intercarpal ligaments of ten fresh human wrists was analyzed in coronal, axial and sagittal images in the neutral position and in radial and ulnar deviation with MR imaging and MR arthrography. The findings were then correlated with gross anatomic inspection. Additionally, quantitative measurements including the radiocarpal distances and capitate angles were performed. RESULTS: Differences were noted in the visual conspicuity of only the intercarpal ligaments of the proximal carpal row with different techniques and wrist positions. The average width of the radiocarpal joint was 0.62 mm, 1.55 mm and 2.0 mm (radial side) and 3.78 mm, 2.25 mm and 1.16 mm (ulnar side) in radial deviation, neutral position, and ulnar deviation of the wrist, respectively. Statistically, these maneuvers produced significant opening in the ulnar side during radial deviation (Student's t-test; P = 0.0005) and in the radial side in ulnar deviation (P = 0.007). CONCLUSION: Significant differences in the width of the radiocarpal joint were observed during radial and ulnar deviation of the wrist, influencing the visualization of the intrinsic ligaments, mainly the scapholunate and lunotriquetral ligaments. The use of MR arthrography with radial and/or ulnar deviation has the potential to improve diagnosis in clinical cases in which injury to one or both of these ligaments is suggested.

Chiasma crurale: intersection of the tibialis posterior and flexor digitorum longus tendons above the ankle. Magnetic resonance imaging-anatomic correlation in cadavers.

PURPOSE: To determine the precise anatomy and magnetic resonance (MR) imaging appearance of the chiasma crurale in cadavers, paying special attention to degenerative changes MATERIAL AND METHODS: Twelve fresh human ankles were harvested from 11 nonembalmed cadavers (mean age at death 77 years) and used according to institutional guidelines. MR imaging and MR tenography were used to investigate the anatomy of the chiasma crurale using proton density-weighted sequences. The gross anatomy of the chiasma crurale was evaluated and compared to the MR imaging findings. Histology was used to elucidate further the structure of the chiasma crurale. RESULTS: Above the chiasma, five specimens had a small amount of fat tissue between the tibialis posterior and flexor digitorum longus tendon. In all specimens both tendons had a sheath below the chiasma but not above it. At the central portion of the chiasma there was no soft tissue between the tendons, except in two specimens that showed an anatomic variant consisting of a thick septum connecting the tibial periosteum and the deep transverse fascia of the leg. In MR images, eight specimens showed what were believed to be degenerative changes in the tendons at the level of the chiasma. However, during gross inspection and histologic analysis of the specimens, there was no tendon degeneration visible. CONCLUSION: At the central portion of the chiasma, there is no tissue between the tibialis posterior and flexor digitorum longus tendons unless there is an anatomic variant. At the chiasma crurale, areas with irregular tendon surfaces are normal findings and are not associated with tendon degeneration (fraying).

Can osseous landmarks in the distal medial humerus be used to identify the attachment sites of ligaments and tendons: paleopathologic-anatomic imaging study in cadavers.

OBJECTIVE: To describe osseous landmarks that allow identification of the attachments of the ligaments and tendons in the distal medial aspect of the humerus. MATERIALS AND METHODS: Reliable osseous landmarks in the distal medial aspect of the humerus were identified in 34 well-preserved specimens from a paleopathologic collection. These osseous landmarks were then sought in magnetic resonance (MR) images of ten cadaveric elbow specimens so that the ease of their visualization and optimal imaging plane could be assessed. To assign these osseous landmarks to specific attachments of the tendons and ligaments in the distal medial humerus, we cut the specimens in slices and photographed and examined them. Subsequently, the prevalence of these osseous landmarks as well as the attachment sites of the tendons and ligaments in this location was determined. RESULTS: We determined ten reliable osseous landmarks in the distal medial aspect of the humerus, their prevalence and ease of identification, and their relationship to the attachments of the tendons and ligaments at the medial distal humerus. CONCLUSION: It is possible to use osseous landmarks at the distal medial humerus to facilitate identification of the different attachments of tendons and ligaments when MR images of the elbow are assessed.

Ulnomeniscal homologue of the wrist: correlation of anatomic and MR imaging findings.

PURPOSE: To evaluate the anatomy of the ulnar side of the wrist in the region of the triangular fibrocartilage (TFC) complex, with special focus on the ulnomeniscal homologue (UMH) and its relationship to surrounding structures. MATERIALS AND METHODS: Institutional review board approval and informed consent were not required. Ten upper extremities were harvested from the nonembalmed cadavers of four women and six men (age range at death, 56-97 years; mean age at death, 83 years) and used according to institutional guidelines. Magnetic resonance (MR) imaging and MR arthrography of the wrist were performed with the wrist in neutral position, maximal ulnar deviation, and maximal radial deviation by using intermediate-weighted sequences. The specimens were cut into 4-mm-thick sections that corresponded to the MR imaging planes. The gross anatomic features of the UMH and its relationship to adjacent structures were evaluated and compared with imaging findings. UMH variants, as described in previous articles on purely anatomic studies, were sought on MR images. MR findings of the wrist in neutral position were compared with those of the wrist in maximal ulnar and radial deviations. Histologic examination was used to further elucidate the structure of the UMH. RESULTS: The UMH displayed complex anatomic features because of its obliquely oriented course. However, it could be divided into styloid, radioulnar, and collateral components and a distal insertion. The UMH variants described in previously published studies could be identified, but evaluation results were highly dependent on the wrist position at imaging. CONCLUSION: The anatomy of the UMH is complex. For assessment of the UMH and the ulnar side of the TFC complex, coronal MR arthrography with the wrist in neutral position or radial deviation might be superior to standard MR imaging.

Ultrasonographic evaluation of degenerative changes in the distal radioulnar joint: correlation of findings with gross anatomy and MR arthrography in cadavers.

OBJECTIVE: To determine the accuracy of ultrasonography (US) in the evaluation of degenerative changes in the distal radioulnar joint (DRUJ). METHODS AND MATERIALS: Ten cadaveric specimens were obtained. US evaluation of cartilage degeneration and thickness was performed by two independent and blinded readers (R1 and R2). Gross anatomy and MR arthrography evaluated by two readers in consensus served as the reference standard. The joint surface not accessible to US was measured. RESULTS: US interreader agreement was non-existent for cartilage thickness measurements and moderate for cartilage degeneration grading (weighted kappa = 0.41). Comparing US and MR imaging evaluation, there was no correlation between US R1 and MR imaging (Pearson correlation coefficient [PCC] = 0.352) and a moderate correlation between US R2 and MR imaging (PCC = 0.570) concerning cartilage thickness measurements. Concerning cartilage degeneration grading, there was a moderate to strong (R1 Spearman correlation coefficient [SCC] = 0.729)/R2 SCC = 0.767) correlation concerning cartilage degeneration grading. Comparing US and gross anatomic evaluation, there was no correlation for US R1 (PCC = 0.220) and a strong correlation for US R2 (PCC = 0.922) concerning cartilage thickness measurements, and a strong to moderate correlation (R1 SCC = 0.808/R2 SCC = 0.597) concerning cartilage degeneration grading. The mean sector of the articular surface of the ulna head not accessible to US was 13°. CONCLUSION: In conclusion the DRUJ is accessible to US except in the central 13° sector of the joint surface. US was approved to be sufficient in demonstrating advanced stages of cartilage degeneration. Thus, US of the DRUJ is recommended in patients suffering from ulnar-sided wrist pain.

Estudo comparativo da deglutição com nasofibrolaringoscopia e videodeglutograma em pacientes com acidente vascular cerebral / Comparison of functional endoscopic swallow study (FESS) vs. videofluoroscopy (VF) in patients with stroke

Os distúrbios da deglutiçäo säo bastante freqüentes nos pacientes neurológicos e naqueles com doenças ou seqüelas de cirurgia de cabeça e pescoço, sendo causa de importante morbidade e mortalidade. Apesar do videodeglutograma (VD) ser considerado o exame de escolha para a avaliaçäo dos distúrbios da deglutiçäo, este exame apresenta limitaçöes em algumas situaçöes clínicas, além de expor o doente à radiaçäo e ao risco de aspiraçäo do contraste. Em anos recentes, têm sido também utilizadas fibras ópticas flexíveis para avaliar os pacientes com disfagia e outras queixas relacionadas à deglutiçäo. OBJETIVO: Análise comparativa entre os dados obtidos pela NFL e VD em relaçäo a parâmetros estudados por ambos métodos. FORMA DE ESTUDO: Caso controle. MATERIAL E MÉTODO: Foram avaliados prospectivamente 12 pacientes com seqüela de acidente vascular cerebral isquêmico, no período de janeiro a maio de 2002, por meio do estudo dinâmico da deglutiçäo com nasofibrolaringoscopia (NFL) e VD, sendo os resultados comparados estatisticamente. RESULTADOS: Enquanto o VD permite a análise da fase preparatória oral e oral da deglutiçäo e o início da fase faríngea, a NFL permite estudo da sensibilidade e mobilidade faringo-laríngea, além da visualizaçäo direta do alimento. Através do teste estatístico McNemar, nenhum dos parâmetros analisados apresentou divergência estatisticamente significante (p<0,05) quando comparados os resultados na NFL e VD. CONCLUSÖES: A análise comparativa entre os dados obtidos pelo NFL e VD em relaçäo a parâmetros avaliados por ambos métodos, em pacientes com disfagia, mostraram näo haver diferenças significativas entre eles