Internal derangement of the wrist: indirect MR arthrography versus unenhanced MR imaging

No Evidence for the Superiority of 3-T Magnetic Resonance Imaging Over 1.5-T Magnetic Resonance Imaging for Diagnosing Wrist Ligamentous Lesions: A Systematic Review and Meta-analysis

PURPOSE

To determine the diagnostic accuracy of native magnetic resonance imaging (MRI) regarding different ligamentous lesions of the wrist and to analyze the influence of technical characteristics, such as field strength, application of fat saturation, 3-dimensional sequences, and wrist coils.

METHODS

A systematic search was performed using MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that were published before February 12, 2024, were included. All studies comparing the diagnostic accuracy of native wrist MRI with that of wrist arthroscopy for suspected ligamentous lesions were included. Results were analyzed by anatomic localization and technical aspects of the MRI. To assess the quality of included studies, we used the revised Quality Assessment of Diagnostic Accuracy Studies tool.

RESULTS

The systematic search revealed 5,181 articles. Thirty-seven studies, reporting 3,893 ligamentous lesions, were eligible for inclusion. The studies displayed heterogeneity in terms of technical conditions, such as field strength, the use of wrist coils, the application of 3-dimensional sequences, and fat saturation. Research methods also varied. Overall sensitivity and specificity were 0.78 (0.66-0.86) and 0.81 (0.70-0.89) for 1.5-T MRI, whereas sensitivity was 0.73 (0.68-0.78) and specificity was 0.90 (0.59-0.98) for 3-T MRI. There was no significant difference between the 2 subgroups (P = .3807 and P = .4248). Sensitivity was 0.82 (0.75-0.87) for triangular fibrocartilage complex lesions, 0.63 (0.50-0.74) for scapholunate ligament tears, and 0.41 (0.25-0.60) for lunotriquetral ligament lesions. Specificity for triangular fibrocartilage complex lesions was 0.82 (0.73-0.89), for scapholunate ligament tears was 0.86 (0.73-0.93), and for lunotriquetral ligament lesions was 0.93 (0.81-0.98).

CONCLUSIONS

The sensitivity and specificity of MRI are influenced by the anatomic location of the lesion and technical conditions. In terms of diagnostic accuracy, no significant difference was found between 1.5-T and 3-T MRI.

LEVEL OF EVIDENCE

Level III, systematic review of Level II-III studies.

Diagnostic accuracy of wrist MRI in comparison to wrist arthroscopy regarding TFCC lesions in clinical practice

INTRODUCTION

The purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment.

METHODS

A total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retrospectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated.

RESULTS

Diagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large.

CONCLUSION

The accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought.

Advanced Imaging of Ulnar Wrist Pain

Ulnar-sided wrist pain can be a diagnostic challenge for clinicians and radiologists. The ulnar wrist has complex morphology and is composed of many small bone and soft tissue structures. Within these structures, a wide variety of pathologic conditions can occur. To successfully diagnose and treat these pathologic conditions, clinicians and radiologists must have a strong understanding of the advanced imaging techniques available to them. In this review, the authors present a brief review of the normal ulnar wrist anatomy, discuss the differential diagnosis of ulnar-sided wrist pain, and examine the indications for different advanced imaging modalities.

Carpal Instability: II. Imaging

Beyond clinical examination, the various forms of carpal instability are assessed with radiologic methods and arthroscopy. For this purpose, the imaging demand for spatial and contrast resolution is particularly high because of the small ligamentous structures involved. The entities of carpal instability are classified into degrees of severity. Early (dynamic) forms of instability can either be indirectly detected with X-ray stress views and cineradiography or by direct visualization of ruptured ligaments in high-resolution magnetic resonance (MR) imaging and MR or computed tomography (CT) arthrography, with the latter the standard of reference in imaging. Advanced (static) forms of carpal instability are sufficiently well detected on radiographs; visualization of early carpal osteoarthritis is superior on CT. To prevent disability of the hand, the radiologist has to provide an early and precise diagnosis. This case-based review highlights the imaging procedures suitable for detection and classification of carpal instability.

MRI of the Wrist Ligaments

Technological advances in magnetic resonance imaging (MRI) have improved radiologists' ability to evaluate wrist ligaments. MRI interpretation often guides clinical management. This article aims to review the normal and pathologic appearance of intrinsic and extrinsic wrist ligaments with a focus on MRI. Variant anatomy, imaging pearls, and clinical significance are also discussed. Special attention is paid to key wrist ligaments that play a role in carpal stability.

Optimization of MRI Protocol for the Musculoskeletal System

자기공명영상(magnetic resonance imaging; 이하 MRI)은 다른 영상 기법에 비해 연부 조직 대조도와 해상력이 높아 근골격계 영역에서 중요한 진단 기기로 이용되고 있다. 최근 MRI 관련 기술이 발달함에 따라 빠른 영상 촬영 및 다양한 영상면 재구성이 가능해짐으로써 입체적인 근골격계 해부학적 구조와 병변을 더욱 잘 평가할 수 있게 되었다. 또한, MRI는 최적화 정도에 따라 영상의 질, 진단 정확도 및 촬영 시간 등이 달라지며, MRI 장치의 효율적 인 운용과도 관련이 있어, 이를 관리하는 것은 영상의학과 의사의 중요한 역할이다. 본 종설에서는 6개 주요 관절에 따른 환자 자세, radiofrequency 코일 선택, 권장 펄스열, 영상면 구성 및 스캔 파라미터에 대한 지침을 제시함으로써 근골격계 MRI의 최적화에 도움이 되고자 한다.

Comparison of MRI & direct MR arthrography with arthroscopy in diagnosing ligament injuries of wrist

Introduction

Ligament injuries around the wrist leading to chronic wrist pain are often a diagnostic dilemma.Various imaging modalities like wrist radiographs, CT and MRI have been used to improve the diagnostic accuracy. The objective of this study was to assess the value of MRI & direct magnetic resonance arthrography (MRA) of the wrist for detecting & evaluating tears of the triangular fibrocartilage complex (TFCC) & scapholunate & luno triquetral interosseous ligament (LTIL & SLIL) injuries in comparison with arthroscopy of the wrist.

Materials & methods

All patients presenting with chronic wrist pain of more than 3 months duration with suspected ligament injuries were included. MRI was performed with 8 channel wrist coil on 1.5 T machine. (PHILIPS, Netherlands). MRA was performed after obtaining consent. Retrospective MR findings were then correlated with results in those patients who underwent arthroscopy. Arthroscopic correlation was obtained in 22 (46.8%) cases out of the 45 patients who underwent both MRI & MRA.

Results

The gold standard arthroscopic procedure diagnosed 15 peripheral & 6 central TFCC tears in 22 patients. 4 scapholunate ligament tears were also identified. MRI diagnosed 16 peripheral & 5 central TFCC tears in these 22 patients. MRA identified 9 central tears and 14 peripheral tears. The sensitivity in diagnosing an overall TFCC tears with MRI as well as MRA was 94.4 & 100%. The specificity of the MRI and MRA in diagnosing an overall TFCC tear was 100% & 75% respectively.

Discussion & conclusions

Direct MRA has better sensitivity in detecting TFCC central tears. In view of 'substantial' agreement between MRI & MRA with Kappa analysis, conventional MRI can be relied on, in diagnosing TFCC injury. With comparatively low specificity, caution and restraint is advised in interpreting MRA, which may influence decision on surgery.

Real-time three-dimensional MRI for the assessment of dynamic carpal instability

Background

Carpal instability is defined as a condition where wrist motion and/or loading creates mechanical dysfunction, resulting in weakness, pain and decreased function. When conventional methods do not identify the instability patterns, yet clinical signs of instability exist, the diagnosis of dynamic instability is often suggested to describe carpal derangement manifested only during the wrist’s active motion or stress. We addressed the question: can advanced MRI techniques provide quantitative means to evaluate dynamic carpal instability and supplement standard static MRI acquisition? Our objectives were to (i) develop a real-time, three-dimensional MRI method to image the carpal joints during their active, uninterrupted motion; and (ii) demonstrate feasibility of the method for assessing metrics relevant to dynamic carpal instability, thus overcoming limitations of standard MRI.

Methods

Twenty wrists (bilateral wrists of ten healthy participants) were scanned during radial-ulnar deviation and clenched-fist maneuvers. Images resulting from two real-time MRI pulse sequences, four sparse data-acquisition schemes, and three constrained image reconstruction techniques were compared. Image quality was assessed via blinded scoring by three radiologists and quantitative imaging metrics.

Results

Real-time MRI data-acquisition employing sparse radial sampling with a gradient-recalled-echo acquisition and constrained iterative reconstruction appeared to provide a practical tradeoff between imaging speed (temporal resolution up to 135 ms per slice) and image quality. The method effectively reduced streaking artifacts arising from data undersampling and enabled the derivation of quantitative measures pertinent to evaluating dynamic carpal instability.

Conclusion

This study demonstrates that real-time, three-dimensional MRI of the moving wrist is feasible and may be useful for the evaluation of dynamic carpal instability.

Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings

PURPOSE

The triangular fibrocartilage complex is one of the most important stabilizers of the wrist and a defect in its anatomical structure is a possible cause of ulnar sided wrist pain. The aim of this study is to compare the diagnostic accuracy between conventional MRI and MR arthrography (MRA) in the depiction of triangular fibrocartilage complex (TFCC) tears.

METHODS-MATERIALS

A total of 60 patients with clinical findings that suggested TFCC tears underwent wrist MRI and MRA. All the MRI and MRA results were compared with the arthroscopic findings.

RESULTS

40 tears were confirmed by arthroscopy. 38/40 tears were identified by MRA while MRI identified 26/40 tears. There were also 8 false positives and 13 false negative results identified by MRI. Two false negative results were identified by MRA. No false positive results were identified.

CONCLUSION

MR arthrography is more sensitive and specific method in terms of the diagnosis of TFCC tears compared to conventional wrist MRI. There was no difference in the diagnostic accuracy between wrist arthroscopy and MRA.

MR arthrography versus conventional MRI and diagnostic arthroscope in patients with chronic wrist pain

Objective

To assess the diagnostic accuracy of direct wrist MR arthrography (MRA) compared to conventional MRI in diagnosis of different pathologic entities causing chronic wrist pain.

Materials and methods

37 consecutive patients 22 males and 15 females, with age range from 16 to 49 years "mean age 28 years" complaining of unexplained chronic wrist pain were prospectively examined by using MRI and MRA with arthroscopic correlation in 25 of them. Findings were divided into 5 main groups of lesions including triangular fibrocartilage complex (TFCC) lesions, ligamentous injuries, osseous lesions, tendon pathology and ganglion.

Results

MRA picked up more ligamentous injuries and triangular fibrocartilage complex (TFCC) lesions that couldn`t be detected on MRI study while both were equal in detection of other types of lesions. TFCC lesions were the most common pathologic findings in both MRI and MRA. Arthroscopic correlation in 25 suspected TFCC lesions (clinically, radiologically or both) revealed that the sensitivity / specificity / accuracy of MRI and MRA were 87.5% / 100% / 96% and 100% / 100% / 100% respectively for central lesions while were 71.4% / 81.3% / 76% and 100% / 90.9% / 96% respectively For peripheral lesions. Extra-capsular lesions, like tenosynovitis and fracture hook of hamate couldn`t be confirmed arthroscopically.

Conclusion

MRA can replace both MRI and diagnostic arthroscopy in detecting causes of chronic wrist pain.

Scaphoid fractures with scapholunate ligament involvement: Instability or ligamentous laxity? Role of arthroscopy and pinning

PURPOSE

Percutaneous fixation of scaphoid fractures often does not allow the evaluation of potential ligamentous lesions. Arthroscopy is an useful tool in the management of scaphoid fractures to visualize potentially associated lesions. With arthroscopic assistance, we often found scapholunate ligament lesions. Our study's aim was to evaluate the role of arthroscopy in the treatment of scaphoid fracture and in particular if the alteration found was a real lesion causing instability or just a paraphysiologic laxity. Furthermore, we evaluated whether the scapholunate joint pinning alters the outcome.

METHODS

We performed a retrospective study on 39 patients (33 males and 6 females), with an average age at trauma of 31.2 years (range 15-67), who underwent surgery for scaphoid fractures between 2010 and 2016 in our Center of Hand Surgery. Patients were divided into four groups based on surgical technique and finding of scapholunate lesions.

RESULTS

Differences between the four groups analyzed, both in terms of clinical scores and ROM, were not statistically significant. This corroborates the hypothesis that all four treatments are equivalent.

CONCLUSIONS

Based on our experience and the literature available, we believe the systematic use of arthroscopy to be useful in patients needing surgical treatment for scaphoid fractures. This is because arthroscopy allows the control of the fracture reduction, screw protrusion evaluation and ligamentous lesions assessment. In cases of partial scapholunate ligament alteration in which no sign of acute lesion is present (hemorrhage and clear rupture), pinning is not necessary since it might just be a paraphysiologic laxity.

LEVEL OF EVIDENCE

IV.

Accuracy of Pre- and Postcontrast, 3 T Indirect MR Arthrography Compared with Wrist Arthroscopy in the Diagnosis of Wrist Ligament Injuries

Background  Magnetic resonance (MR) is the most important imaging technique to assess intra-articular pathology of the wrist. Among various MR imaging protocols, the diagnostic performance of indirect MR arthrography needs further investigation. Purpose  The purpose of this study was to assess the diagnostic performance of pre- and postcontrast, 3 T indirect MR arthrography in the diagnosis of scapholunate intrinsic ligament (SLIL) and triangular fibrocartilage complex (TFCC) injuries, using wrist arthroscopy as reference standard. Patients and Methods  We retrospectively evaluated consecutive patients with suspected SLIL or TFCC injury, who had indirect MR arthrography done before arthroscopy. Images were assessed independently by two senior radiologists. Results  Arthroscopy of the 53 wrists demonstrated 16 Geissler stages II and III partial tears and 6 stage IV total SLIL ruptures. Central perforation of the TFCC was found in 24 wrists, and 12 wrists had an ulnar class 1B lesion. To detect any SLIL tear, accuracy was higher for the two observers using postcontrast indirect MR arthrography (0.77 and 0.72) than for precontrast MR imaging (0.60 and 0.60). No difference was found for total SLIL ruptures "0.85 and 0.89" versus "0.85 and 0.89." To diagnose class 1B TFCC injuries, accuracy was higher using postcontrast indirect MR arthrography (0.85 and 0.75) than for precontrast MR imaging (0.70 and 0.72). No difference in accuracy was demonstrated for TFCC central tears "0.75 and 0.75" versus "0.70 and 0.77." Conclusion  Postcontrast images at 3 T indirect MR arthrography, compared with precontrast images, have an improved diagnostic performance for the overall detection of SLIL injuries and as well as class 1B TFCC tears. Level of Evidence  This is a Level II, diagnostic study.

TFCC Injuries: Meta-Analysis and Comparison of Diagnostic Imaging Modalities

Background  Imaging of the triangular fibrocartilaginous complex (TFCC) remains difficult, as no single imaging modality demonstrates perfect sensitivity and specificity. Purpose  This study performs a meta-analysis of multiple previous publications to guide noninvasive imaging selection for the diagnosis of TFCC injuries. Methods  A literature search was performed and conducted. Studies were included that compared the diagnostic accuracy of magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and computed tomography (CT)/computed tomographic arthrography (CTA) for the evaluation of TFCC injuries. All studies included either arthroscopic or open surgical findings as the "gold standard." A meta-analysis was performed comparing the diagnostic accuracy of MRA, MRI, and CT for the detection of TFCC injuries. Results  Initial search returned 2,568 candidate articles. Studies were then reviewed and narrowed yielding a total of 28 independent studies (20 MRI, 9 MRA, 4 CT/CTA with some studies including multiple modalities) considered in the qualitative data synthesis. Pooling of the raw data in a meta-analysis demonstrated sensitivities of 0.76 (0.72-0.80), 0.78(0.70-0.84), and 0.89 (0.81-0.95) for MRI, MRA, and CT arthrogram, respectively, with specificities of 0.82 (0.77-0.86), 0.85 (0.77-0.92), and 0.89 (0.81-0.95), respectively. Additionally, across all imaging modalities, diagnostic accuracy was highest for central TFCC lesions versus peripheral lesions. Conclusion  This study represents the largest meta-analysis to date to compare multiple imaging modalities for the diagnosis of TFCC injuries. Pooled data demonstrated that CTA and MRA had statistically equivalent sensitivity and specificity for the diagnosis of TFCC injuries. Diagnostic accuracy was highest for central TFCC injuries.

An Evaluation of the Reliability of Wrist Arthroscopy in the Assessment of Tears of the Triangular Fibrocartilage Complex

PURPOSE

Wrist arthroscopy is generally considered the reference standard in the diagnosis of triangular fibrocartilage complex (TFCC) injuries. There is a paucity of data examining the reliability of wrist arthroscopy as a diagnostic modality for TFCC injuries. The goal of this study was to evaluate the interobserver and intraobserver reliability of the diagnosis of TFCC pathology during wrist arthroscopy.

METHODS

Twenty-five intraoperative digital videos were captured by the senior author during diagnostic and surgical arthroscopy of the wrist joint for known or suspected articular pathology. The senior author (P.K.B.) confirmed TFCC resilience on visual inspection and ballottement (trampoline effect) to make the diagnosis. Two videos were excluded for poor quality and inadequate visualization. Three hand surgeons subsequently reviewed the remaining 23 videos in a blinded fashion at 2 time points separated by 4 weeks. The reviewers determined if the trampoline test was positive and if a TFCC tear was present. Tears were classified using a morphologic classification. Statistical measures of reliability including percentage agreement and κ coefficients were calculated.

RESULTS

Agreement between observers for the presence or absence of a tear was 66.7%. The average intraobserver agreement regarding the presence or absence of a tear was 67.4% The kappa value for interobserver agreement was 0.33, whereas the intrarater agreement was 0.88. The 3 reviewers identified an average of 11.3 positive trampoline tests. Agreement between observers for a positive trampoline test was 65.2%. The average percentage of intraobserver agreement regarding a positive trampoline test was 49.3%. In cases where all 3 reviewers agreed on the presence of a TFCC tear, the agreement regarding tear location was 76.6%.

CONCLUSIONS

Wrist arthroscopy remains instrumental in the treatment of TFCC tears. However, given that inter-rater reliability in the assessment of these tears is probably too low, reconsideration should be given to arthroscopy as the reference standard in the diagnosis of these tears.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Anatomy and injuries of the pediatric wrist: beyond the basics

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.

MR arthrography is slightly more accurate than conventional MRI in detecting TFCC lesions of the wrist

Introduction

In case of clinical suspicion of triangular fibrocartilage complex (TFCC) injury, different imaging techniques are used. The aim of this study was to determine whether MRA is superior to MRI and whether 3.0 T is better than 1.5 T (expresses in sensitivity, specificity and accuracy) in detecting TFCC injury, using arthroscopy as the gold standard.

Materials and methods

The arthroscopic and MR findings of 150 patients who underwent arthroscopy for ulnar-sided wrist pain between January 2009 and November 2016 were retrospectively reviewed.

Results

MRA was slightly more accurate compared to conventional MRI, and 1.5 T was slightly more accurate than 3.0 T. 1.5 T wrist MRA had a sensitivity of 80%, a specificity of 100% and accuracy of 90%; 3.0 T wrist MRA 73, 100 and 86%, resp. Conventional 1.5 T wrist MRI had a sensitivity of 71%, a specificity of 75% and accuracy of 73%. For 3.0 T conventional MRI, this was 73, 67 and 70%, resp.

Conclusions

MRA seems slightly superior to conventional MRI, but one could question whether this difference in diagnostic accuracy outweighs the burden and risks of an invasive procedure for patients with its additional costs. Furthermore, we could not confirm the superiority of 3 T compared to 1.5 T.

MR imaging of the traumatic triangular fibrocartilaginous complex tear

Triangular fibrocartilage complex is a major stabilizer of the distal radioulnar joint (DRUJ). However, triangular fibrocartilage complex (TFCC) tear is difficult to be diagnosed on MRI for its intrinsic small and thin structure with complex anatomy. The purpose of this article is to review the anatomy of TFCC, state of art MRI imaging technique, normal appearance and features of tear on MRI according to the Palmar's classification. Atypical tear and limitations of MRI in diagnosis of TFCC tear are also discussed.

Diagnostic accuracy of single-compartment magnetic resonance arthrography in detecting common causes of chronic wrist pain

We reviewed a series of 50 consecutive wrist arthroscopy patients who had been investigated pre-operatively by direct magnetic resonance arthrography and calculated the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of magnetic resonance arthrography in detecting full-thickness triangular fibrocartilage complex tears, intrinsic carpal ligamentous lesions, wrist synovitis and chondral lesions in the radiocarpal joint. The sensitivities of magnetic resonance arthrography in detecting central triangular fibrocartilage complex tears, peripheral triangular fibrocartilage complex tears, scapholunate ligament tears, lunotriquetral ligament tears, dorsal synovitis and radiocarpal chondral lesions were 89%, 63%, 71%, 100%, 32% and 65%, respectively, and its specificities in detecting these lesions were 91%, 98%, 89%, 94% 94% and 97%, respectively. This study suggests that single compartment direct wrist magnetic resonance arthrography can provide high diagnostic accuracy for full-thickness triangular fibrocartilage lesions, intrinsic carpal ligament tears and chondral lesions in the radiocarpal joint, but that it is much less accurate in diagnosing synovitis of the radiocarpal joint.

LEVEL OF EVIDENCE

III.

Diagnostic modalities for distal radioulnar joint

The first imaging modality in patients suspected of distal radioulnar joint pathology should be conventional radiography to exclude or diagnose wrist pathology including osteoarthritis, rheumatoid arthritis, calcium pyrophosphate deposition disease, (healed) fractures, or impaction syndromes. When conventional radiography is inconclusive, high resolution 3 Tesla magnetic resonance imaging is advised. We provide a broad overview of the literature regarding the use of intra-articular contrast both with computed tomography (CTA) or magnetic resonance imaging (MRA). Conventional arthrography and unenhanced computed tomography are not indicated. This article discusses the most useful imaging techniques in terms of clinical indications, patient positioning, technical imaging requirements, and diagnostic performance in patients with suspected distal radioulnar joint pathology. Furthermore, the most prevalent pathologies are discussed, with the focus on imaging characteristics in both stable and unstable distal radioulnar joints.

Scapholunate Interosseous Ligament Tears: Diagnostic Performance of 1.5 T, 3 T MRI, and MR Arthrography-A Systematic Review and Meta-analysis

RATIONALE AND OBJECTIVES

The study aimed to perform a systematic review and meta-analysis for evaluating the diagnostic accuracy of 1.5 Tesla and 3.0 Tesla magnetic resonance imaging (MRI), and magnetic resonance arthrography (MRA), in the detection of scapholunate interosseous ligament (SLIL) injury.

MATERIALS AND METHODS

A literature search was performed (until July 2015) using the PubMed (MEDLINE), Embase, ISI Web of Science, Scopus, and conference proceedings. Original studies evaluating the diagnostic accuracy of MRI or MRA in the detection of SLIL injuries using arthroscopy or open surgery as the reference standard were included.

RESULTS

Of the initial 930 published records and 103 conference proceedings, 24 studies (1902 MRI examinations) were included (median SLIL injury prevalence: 33% [interquartile range: 25-42]). Heterogeneity was detected for 1.5 T MRI (chi-square: 47.93, P < 0.001) but not for 3.0 T MRI (chi-square: 8.00, P value: 0.09) and MRA (chi-square: 14.54, P value: 0.34) studies. The sensitivities of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 45.7% (95% confidence interval: 40.1-51.4), 75.7% (66.8-83.2), and 82.1% (76.1-87.2), respectively. The specificities of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 80.5% (77.3-83.4), 97.1% (89.8-99.6), and 92.8% (90.2-94.9), respectively. The diagnostic odds ratios of 1.5 T MRI, 3.0 T MRI, and MRA for detection of SLIL injury were 5.56 (2.71-11.39), 23.23 (3.16-171.00), and 65.04 (32.89-128.62) (P value < 0.001), respectively. The results were consistent after addressing publication bias and sensitivity analyses.

CONCLUSIONS

MRA is superior to 3.0 T MRI, and 3.0 T MRI is superior to 1.5 T MRI in terms of diagnostic performance. 3.0 T MRI has the highest specificity for the detection of SLIL injuries.

Imaging in carpal instability

Carpal instability is a complex and heterogeneous clinical condition. Management requires accurate identification of structural injury with an understanding of the resultant movement (kinematic) and load transfer (kinetic) failure. Static imaging techniques, such as plain film radiography, stress views, ultrasound, magnetic resonance, MR arthrography and computerized tomography arthrography, may accurately depict major wrist ligamentous injury. Dynamic ultrasound and videofluoroscopy may demonstrate dynamic instability and kinematic dysfunction. There is a growing evidence base for the diagnostic accuracy of these techniques in detecting intrinsic ligament tears, but there are limitations. Evidence of their efficacy and relevance in detection of non-dissociative carpal instability and extrinsic ligament tears is weak. Further research into the accuracy of existing imaging modalities is still required. Novel techniques, including four-dimensional computerized tomography and magnetic resonance, can evaluate both cross-sectional and functional carpal anatomy. This is a narrative review of level-III studies evaluating the role of imaging in carpal instability.

Advanced imaging of the scapholunate ligamentous complex

The scapholunate joint is one of the most involved in wrist injuries. Its stability depends on primary and secondary stabilisers forming together the scapholunate complex. This ligamentous complex is often evaluated by wrist arthroscopy. To avoid surgery as diagnostic procedure, optimization of MR imaging parameters as use of three-dimensional (3D) sequences with very thin slices and high spatial resolution, is needed to detect lesions of the intrinsic and extrinsic ligaments of the scapholunate complex. The paper reviews the literature on imaging of radial-sided carpal ligaments with advanced computed tomographic arthrography (CTA) and magnetic resonance arthrography (MRA) to evaluate the scapholunate complex. Anatomy and pathology of the ligamentous complex are described and illustrated with CTA, MRA and corresponding arthroscopy. Sprains, mid-substance tears, avulsions and fibrous infiltrations of carpal ligaments could be identified on CTA and MRA images using 3D fat-saturated PD and 3D DESS (dual echo with steady-state precession) sequences with 0.5-mm-thick slices. Imaging signs of scapholunate complex pathology include: discontinuity, nonvisualization, changes in signal intensity, contrast extravasation (MRA), contour irregularity and waviness and periligamentous infiltration by edema, granulation tissue or fibrosis. Based on this preliminary experience, we believe that 3 T MRA using 3D sequences with 0.5-mm-thick slices and multiplanar reconstructions is capable to evaluate the scapholunate complex and could help to reduce the number of diagnostic arthroscopies.

Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures

The prevalence of ligamentous injury associated with fractures of the distal radius is reported to be as high as 69% with injury to the scapholunate interosseous ligament and lunotriquetral interosseous ligament occurring in 16% to 40% and 8.5% to 15%, respectively. There is a lack of consensus on which patients should undergo advanced imaging, arthroscopy, and treatment and whether this changes their natural history. Overall, patients with high-grade intercarpal ligament injuries are shown to have longer-term disability and sequelae compared with those with lower-grade injuries. This article reviews the diagnosis and treatment options for these injuries.

The performance of magnetic resonance imaging in the detection of triangular fibrocartilage complex injury: a meta-analysis

The aim of this study was to evaluate the accuracy of magnetic resonance imaging in the detection of triangular fibrocartilage complex injury through a meta-analysis. A comprehensive literature search was conducted before 1 April 2014. All studies comparing magnetic resonance imaging results with arthroscopy or open surgery findings were reviewed, and 25 studies that satisfied the eligibility criteria were included. Data were pooled to yield pooled sensitivity and specificity, which were respectively 0.83 and 0.82. In detection of central and peripheral tears, magnetic resonance imaging had respectively a pooled sensitivity of 0.90 and 0.88 and a pooled specificity of 0.97 and 0.97. Six high-quality studies using Ringler's recommended magnetic resonance imaging parameters were selected for analysis to determine whether optimal imaging protocols yielded better results. The pooled sensitivity and specificity of these six studies were 0.92 and 0.82, respectively. The overall accuracy of magnetic resonance imaging was acceptable. For peripheral tears, the pooled data showed a relatively high accuracy. Magnetic resonance imaging with appropriate parameters are an ideal method for diagnosing different types of triangular fibrocartilage complex tears.

Update TFCC: histology and pathology, classification, examination and diagnostics

The TFCC is a crucial stabilizer of the DRUJ. Based on its superficial and deep fibers, the TFCC guarantees unrestricted pronation and supination which is essential for performing sophisticated tasks. The ability to perform complex movements is of uppermost importance for hand function. Therefore, a functional intact TFCC is a prerequisite in this context. The articular disc of the TFCC is a fibrocartilaginous extension of the superficial zone of hyaline articular cartilage which arises from the radius. The peripheral 10-40 % of the TFC is vascularized. Degeneration of the articular disc is common with increasing age. Even though the central part of the articular disc is avascular, potential regeneration of lesions could be detected. The Palmer and Atzei classifications of TFCC lesions are complementary. TFCC innervation is based on different nerves. There is a high variability. A diligent clinical examination facilitates specific tests which help to allocate symptoms to the pathology. Therefore, a thorough clinical examination is not dispensable. Wrist arthroscopy remains the "gold standard" for diagnosing TFCC pathologies despite technical progress in imaging modalities. MR arthrography may have the potential to become a real alternative to wrist arthroscopy for diagnosing TFCC pathologies with technical progress in the future.

Computed tomography arthrography using a radial plane view for the detection of triangular fibrocartilage complex foveal tears

PURPOSE

To classify triangular fibrocartilage complex (TFCC) foveal lesions on the basis of computed tomography (CT) arthrography using a radial plane view and to correlate the CT arthrography results with surgical findings. We also tested the interobserver and intra-observer reliability of the radial plane view.

METHODS

A total of 33 patients with a suspected TFCC foveal tear who had undergone wrist CT arthrography and subsequent surgical exploration were enrolled. We classified the configurations of TFCC foveal lesions into 5 types on the basis of CT arthrography with the radial plane view in which the image slices rotate clockwise centered on the ulnar styloid process. Sensitivity, specificity, and positive predictive values were calculated for each type of foveal lesion in CT arthrography to detect foveal tears. We determined interobserver and intra-observer agreements using kappa statistics. We also compared accuracies with the radial plane views with those with the coronal plane views.

RESULTS

Among the tear types on CT arthrography, type 3, a roundish defect at the fovea, and type 4, a large defect at the overall ulnar insertion, had high specificity and positive predictive value for the detection of foveal tears. Specificity and positive predictive values were 90% and 89% for type 3 and 100% and 100% for type 4, respectively, whereas sensitivity was 35% for type 3 and 22% for type 4. Interobserver and intra-observer agreement was substantial and almost perfect, respectively. The radial plane view identified foveal lesion of each palmar and dorsal radioulnar ligament separately, but accuracy results with the radial plane views were not statistically different from those with the coronal plane views.

CONCLUSIONS

Computed tomography arthrography with a radial plane view exhibited enhanced specificity and positive predictive value when a type 3 or 4 lesion was identified in the detection of a TFCC foveal tear compared with historical controls.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

[Detection of intrinsic ligament and TFCC lesions of the wrist. Direct versus indirect MRI arthrography]

BACKGROUND

The purpose of this study was to validate the diagnostic value of direct magnetic resonance imaging (dMRI) arthrography and indirect MRI (iMRI) arthrography concerning intrinsic ligament injuries and tears of the triangular fibrocartilage complex (TFCC).

PATIENTS AND METHODS

A randomized prospective trial was conducted with patients who presented with wrist pain potentially due to carpal lesions and 10 patients aged 19-60 years (3 female and 7 male) were included. Between the clinical examination and the diagnostic and therapeutic arthroscopy, dMRI and iMRI arthrography were performed for the diagnostics of injuries of the intrinsic ligaments or the TFCC. The results of dMRI and iMRI arthrography were evaluated by two radiologists blinded to the injuries of the patients and a consensus was reached. The results were compared with the findings obtained by arthroscopy.

RESULTS

In the arthroscopy five lesions of the scapholunate ligament (SL), one of the lunotriquetral ligament (LT) and seven of the TFCC were identified. The sensitivity of iMRI and dMRI for carpal ligament lesions (SL and LT) was low (50 %) whereas the specificity was high (93 %). For injuries of the TFCC the sensitivity (up to 100 %) and the specificity (100 %) were both excellent. The area under the curve (AUC) in the receiver operating characteristics (ROC) analysis was high for TFCC lesions in both dMRI and iMRI arthrography.

CONCLUSION

Indirect MRI arthrography is a suitable method for detection of injuries of the TFCC and intrinsic ligaments of the wrist with good sensitivity and specificity. Despite the low number of patients the results of this study showed that there were no essential differences between dMRI and iMRI arthrography with respect to the diagnostic value for carpal injuries of the wrist.

Imaging of radial wrist pain. I. Imaging modalities and anatomy

Radial wrist pain is a common clinical complaint. The relatively complex anatomy in this region, combined with the small size of the anatomical structures and occasionally subtle imaging findings, can pose problems when trying to localize the exact cause of pain. To fully comprehend the underlying pathology, one needs a good understanding of both radial-sided wrist anatomy and the relative merits of the different imaging techniques used to assess these structures. In part I of this review, these aspects will be discussed.

Intraobserver and interobserver variability in diagnosing scapholunate dissociation by cineradiography

PURPOSE

To evaluate the intraobserver and interobserver variability in diagnosing scapholunate dissociation (SLD) by wrist cineradiography.

METHODS

A musculoskeletal radiologist, hand surgeon, and trauma surgeon assessed the records of 50 consecutive wrist cineradiographies performed in 25 patients. Fluoroscopy was performed on the unaffected and affected wrist and consisted of radiographer-controlled passive flexion-extension and passive radial-ulnar deviation in both posteroanterior and lateral projections. To determine the intraobserver variability, the 3 reviewers reassessed all wrist cineradiographies 6 months after their first assessment. The kappa coefficient for interobserver agreement was calculated using the jackknife method. The Cohen kappa was used to assess intraobserver variability.

RESULTS

The interobserver variability for diagnosing SLD by cineradiography was excellent (κ = 0.84). The intraobserver variability for the hand surgeon was excellent (κ = 0.80), and was good for the radiologist (κ = 0.72) and the trauma surgeon (κ = 0.76).

CONCLUSIONS

Cineradiography is a promising and helpful, noninvasive tool for diagnosing SLD. It is widely available and has relatively low costs. Conventional radiographs remain essential in the primary workup for suspected SLD. However, we recommend cineradiography when an SLD is clinically suspected.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

The diagnostic accuracy of wrist cineradiography in diagnosing scapholunate dissociation

Ruptures of the scapholunate ligament (SLL) may cause carpal instability, also known as scapholunate dissociation (SLD). SLD may lead to osteoarthritis of the radiocarpal and midcarpal joints. The aim of this retrospective study was to determine the diagnostic value of wrist cineradiography in detecting SLD. All cineradiographic studies made during a 24 year period were retrieved. All patients who underwent the confirmation method (arthroscopy and/or arthrotomy) and cineradiography were included. In total, 84 patients met the inclusion criteria. Sensitivity, specificity, likelihood ratio, positive predictive value, negative predictive value, and diagnostic accuracy for detecting SLD were calculated for radiography and cineradiography. Cineradiography had a sensitivity of 90%, a specificity of 97%, and a diagnostic accuracy of 0.93 in detecting SLD. Radiography had a sensitivity of 81%, a specificity of 80%, and a diagnostic accuracy of 0.81. Cineradiography has a high diagnostic value for diagnosing SLDs. A positive cineradiography markedly increases the post-test probability of SLD.

Real-time magnetic resonance imaging (MRI) during active wrist motion--initial observations

BACKGROUND

Non-invasive imaging techniques such as magnetic resonance imaging (MRI) provide the ability to evaluate the complex anatomy of bone and soft tissues of the wrist without the use of ionizing radiation. Dynamic instability of wrist--occurring during joint motion--is a complex condition that has assumed increased importance in musculoskeletal medicine. The objective of this study was to develop an MRI protocol for evaluating the wrist during continuous active motion, to show that dynamic imaging of the wrist is realizable, and to demonstrate that the resulting anatomical images enable the measurement of metrics commonly evaluated for dynamic wrist instability.

METHODS

A 3-Tesla "active-MRI" protocol was developed using a bSSFP sequence with 475 ms temporal resolution for continuous imaging of the moving wrist. Fifteen wrists of 10 asymptomatic volunteers were scanned during active supination/pronation, radial/ulnar deviation, "clenched-fist", and volarflexion/dorsiflexion maneuvers. Two physicians evaluated distal radioulnar joint (DRUJ) congruity, extensor carpi ulnaris (ECU) tendon translation, the scapholunate (SL) interval, and the SL, radiolunate (RL) and capitolunate (CL) angles from the resulting images.

RESULTS

The mean DRUJ subluxation ratio was 0.04 in supination, 0.10 in neutral, and 0.14 in pronation. The ECU tendon was subluxated or translated out of its groove in 3 wrists in pronation, 9 wrists in neutral, and 11 wrists in supination. The mean SL interval was 1.43 mm for neutral, ulnar deviation, radial deviation positions, and increased to 1.64 mm during the clenched-fist maneuver. Measurement of SL, RL and CL angles in neutral and dorsiflexion was also accomplished.

CONCLUSION

This study demonstrates the initial performance of active-MRI, which may be useful in the investigation of dynamic wrist instability in vivo.

MRI of wrist ligaments

The optimal imaging protocols for magnetic resonance imaging (MRI) of the wrist ligaments are discussed, including the use of magnetic resonance arthrography, and 3 Tesla (T) versus 1.5 T magnetic field strength. The normal MRI appearance of the triangular fibrocartilage complex, capsular, and interosseous wrist ligaments is briefly covered to point out potential diagnostic pitfalls. Numerous examples of common ligamentous pathology discernible on MRI are provided, along with the latest estimates of diagnostic sensitivity and specificity provided by the literature.

Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography

PURPOSE

This study compares the diagnostic performance of multidetector CT arthrography (CTA), conventional 3-T MR and MR arthrography (MRA) in detecting intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist.

MATERIALS AND METHODS

Ten cadaveric wrists of five male subjects with an average age 49.6years (range 26-59years) were evaluated using CTA, conventional 3-T MR and MRA. We assessed the presence of scapholunate ligament (SLL), lunotriquetral ligament (LTL), and TFCC tears using a combination of conventional arthrography and arthroscopy as a gold standard. All images were evaluated in consensus by two musculoskeletal radiologists with sensitivity, specificity, and accuracy being calculated.

RESULTS

Sensitivities/specificity/accuracy of CTA, conventional MRI, and MRA were 100%/100%/100%, 66%/86%/80%, 100%/86%/90% for the detection of SLL tear, 100%/80%/90%, 60%/80%/70%, 100%/80%/90% for the detection of LTL tear, and 100%/100%/100%, 100%/86%/90%, 100%/100%/100% for the detection of TFCC tear. Overall CTA had the highest sensitivity, specificity, and accuracy among the three investigations while MRA performed better than conventional MR. CTA also had the highest sensitivity, specificity, and accuracy for identifying which component of the SLL and LTL was torn. Membranous tears of both SLL and LTL were better visualized than dorsal or volar tears on all three imaging modalities.

CONCLUSION

Both CT and MR arthrography have a very high degree of accuracy for diagnosing tears of the SLL, LTL, and TFCC with both being more accurate than conventional MR imaging.

Utility of magnetic resonance imaging for detection of longitudinal split tear of the ulnotriquetral ligament

PURPOSE

Wrist magnetic resonance imaging (MRI) has established utility in the diagnosis of wrist ligament tears, including complete tears of the ulnotriquetral ligament (UTL) and other components of the triangular fibrocartilage complex. A new type of longitudinal split tear of the UTL has recently been described with no imaging correlate. Our aims were to describe putative MRI findings associated with longitudinal UTL split tears and to assess diagnostic accuracy.

METHODS

We randomly selected 40 patients with arthroscopically proven longitudinal UTL split tears and 20 patients with intact UTLs, all of whom had preoperative 3 T MRI of the same wrist performed, from a list of operative notes spanning from January 1997 through October 2011, filtered with the terms "ulnotriquetral ligament" and "ulnar triquetral ligament." Two musculoskeletal radiologists who were blinded to surgical results and clinical information independently reviewed the exams. They recorded the degree of certainty of whether a longitudinal UTL split tear was present and whether several other hypothesized associated abnormalities were present.

RESULTS

Overall sensitivity for definitive longitudinal UTL split tear detection on MRI was 58% for reader 1 and 30% for reader 2. Specificity was 60% for both. There were no statistically significant discriminatory findings.

CONCLUSIONS

Among a selected group of patients who all had wrist arthroscopy, preoperative noncontrast 3 T wrist MRI had poor sensitivity and specificity for detection of the longitudinal split type of UTL tear. To date, MRI may be more helpful to exclude potential alternative diagnoses in the patient with ulnar wrist pain.

Trends in wrist arthroscopy

Background Wrist arthroscopy plays a role in both the diagnosis and the treatment of wrist pathology. It has evolved in the last three decades. Questions The present status of wrist arthroscopy was investigated by answering the following questions: -What is its current position in the treatment wrist pathologies according to the literature? -What is its current position according to hand surgeons? Methods Analysis of the number of publications on wrist arthroscopy was performed and compared with the number of publications on other arthroscopy topics to assess the current position of wrist arthroscopy. The members of the EWAS (European Wrist Arthroscopy Society) and the members of eight national hand surgery societies were questioned on wrist arthroscopy in daily practice. Results From 1975 till now, 925 papers on wrist arthroscopy were found. The publications on wrist arthroscopy increased from an average of 8/year (1986) to 26/year (2012). More than half (56.9%) of the respondents of the EWAS perform fewer than 5 wrist arthroscopies per month, and only 7 (10.8%) indicate the performance of more than 10 wrist arthroscopies per month. Seventy-four percent of the orthopedic hand surgeons perform wrist arthroscopy (in 48.5% for therapeutic indications) against 36.8% of plastic surgery hand surgeons (in 23.1% for therapeutic indications). Conclusion Wrist arthroscopy has taken up a place in the armamentarium of the hand surgeon. The place of wrist arthroscopy in daily practice is related to the background of the hand surgeon.

The role of wrist magnetic resonance arthrography in diagnosing triangular fibrocartilage complex tears: experience at king hussein medical center, jordan

OBJECTIVES

The aims of the study were to evaluate the role of magnetic resonance arthrography (MRA) of the wrist in detecting full-thickness tears of the triangular fibrocartilage complex (TFCC) and to compare the results of the magnetic resonance arthrography (MRA) with the gold standard arthroscopic findings.

METHODS

The study was performed at King Hussein Medical Center, Amman, Jordan, between January 2008 and December 2011. A total of 42 patients (35 males and 7 females) who had ulnar-sided wrist pain and clinical suspicions of TFCC tears were included in the study. All patients underwent wrist magnetic resonance arthrography (MRA) and then a wrist arthroscopy. The results of MRA were compared with the arthroscopic findings.

RESULTS

After comparison with the arthroscopic findings, the MRA had three false-negative results (sensitivity = 93%) and no false-positive results. A total of 39 patients were able to return to work. Satisfaction was high in 38 of the patients and 33 had satisfactory pain relief. The sensitivity of the wrist MRA in detecting TFCC full-thickness tears was 93% (39), and specificity was 80% (16/20). The overall accuracy of wrist arthroscopy in detecting a full-thickness tear of the TFCC in our study was 85% (29/34).

CONCLUSION

These results illustrate the role of wrist MRA in assessing the TFCC pathology and suggest its use as the first imaging technique, following a plain X-ray, in evaluating patients with chronic ulnar side wrist pain with suspected TFCC injuries.

Scapholunate instability: current concepts in diagnosis and management

Injuries to the scapholunate joint are the most frequent cause of carpal instability and account for a considerable degree of wrist dysfunction, lost time from work, and interference with activities. Although it is insufficient to cause abnormal carpal posture or collapse on static radiographs, an isolated injury to the scapholunate interosseous ligament may be the harbinger of a relentless progression to abnormal joint mechanics, cartilage wear, and degenerative changes. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics. In this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate articulation and provide a foundation for understanding the spectrum of scapholunate ligament instability. We propose an algorithm for treatment based on the stage of injury and the degree of secondary ligamentous damage and arthritic change.

Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis

BACKGROUND

Triangular fibrocartilaginous complex (TFCC) tears are common sources of ulnar-sided wrist pain and resultant functional disability. Diagnosis is based on the history and clinical examination as well as radiographic evidence of a TFCC central perforation or a radial/ulnar tear. The purpose of this study was therefore to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in the detection of TFCC injury in the adult population.

METHODS

Published and unpublished literature databases were searched. Two-by-two tables were constructed to calculate the sensitivity and specificity of MRI or MRA investigations against arthroscopic outcomes. Pooled sensitivity and specificity values and summary receiver operating characteristic curve evaluations were performed. The methodological quality of each study was assessed with use of the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool.

RESULTS

Twenty-one studies were included in the review, and these series included a total of 982 wrists. On meta-analysis, MRA was superior to MRI in the investigation of full-thickness TFCC tears, with a pooled sensitivity of 0.75 and a pooled specificity of 0.81 for MRI compared with 0.84 and 0.95, respectively, for MRA. MRA and MRI performed at greater field strengths were reported to have greater sensitivity and specificity than those performed at lower field strengths. There were insufficient data to assess the diagnostic test accuracy for partial-thickness TFCC tears.

CONCLUSIONS

Given its acceptable diagnostic test accuracy, it is recommended that MRA, rather than MRI, be performed in when there are questions about the diagnosis and subsequent management of patients with ulnar-sided wrist pain.

Prevalence of triangular fibrocartilage complex abnormalities on MRI scans of asymptomatic wrists

PURPOSE

Magnetic resonance imaging (MRI) of the wrist is increasingly used in the diagnosis of ulnar-sided wrist pain; however, its efficacy in this setting still needs clarification. The purposes of this study were to investigate the prevalence of abnormal MRI findings in the triangular fibrocartilage complex (TFCC) in asymptomatic volunteers and to provide the clinician with comparative data when interpreting MRI results.

METHODS

A total of 103 asymptomatic volunteers underwent imaging of the wrist using a 1.9-T MR scanner and a send-receive birdcage quadrature coil. The images were evaluated by 3 independent interpreters, 2 musculoskeletal radiologists, and 1 orthopedic hand surgeon. We noted details regarding the TFCC morphology and the presence, characteristics, and location of any TFCC abnormality.

RESULTS

The TFCC was considered abnormal in 39 wrists. The scans were abnormal in 31 subjects younger than 50 years of age, in 5 subjects 50 to 59 years of age, and in all subjects older than 60 years of age (3 subjects). We diagnosed a complete tear of the TFCC in 23 wrists. An increase in age was correlated with an abnormal TFCC (r(pb) = 0.23; P = .016).

CONCLUSIONS

The prevalence of incidental TFCC findings in MRI scans of asymptomatic subjects is high. The presence of an abnormal TFCC on MRI may be of questionable clinical meaning, because there is a high incidence of TFCC abnormalities in asymptomatic subjects, particularly those over the age of 50. Imaging results must be viewed in the context of the clinical history and physical examination.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Matrix-induced autologous chondrocyte implantation of the knee: mid-term and long-term follow-up by MR arthrography

OBJECTIVE

To define magnetic resonance (MR) arthrography imaging findings of matrix-induced autologous chondrocyte implantation (MACI) grafts of the knee in order to describe implant behaviour and to compare findings with validated clinical scores 30 and 60 months after MACI implant.

MATERIALS AND METHODS

Thirteen patients were recruited (10 male, 3 female) with a total number of 15 chondral lesions. Each patient underwent an MACI procedure and MR arthrography 30 and 60 months after surgery. MR arthrography was performed using a dedicated coil with a 1.5-Tesla unit. The status of the chondral implant was evaluated with the modified MOCART scoring scale. The lining of the implant, the integration to the border zone, the surface and structure of the repaired tissue were assessed, and the presence of bone marrow oedema and effusion was evaluated. For clinical assessment, the Cincinnati score was used.

RESULTS

At 60 months, the abnormality showed worsening in 1 out of 15 cases. Integration showed improvement in 3 out of 15 cases, and worsening in 3 out of 15 cases. Two surfaces of the implant showed further deterioration at 60 months, and 1 afflicted implant fully recovered after the same time interval. Implant contrast enhancement at 30 months was seen in 2 out of 15 cases, 1 of which recovered at 60 months. According to the MOCART score, 4 cases were rated 68.4 out of 75 at 30 months and 65 out of 75 at 60 months. The mean clinical score decreased from 8.6 out of 10 at 30 months to 8.1 out of 10 at 60 months.

CONCLUSION

Magnetic resonance arthrography improved the evaluation of implants and facilitated the characterisation of MACI integration with contiguous tissues. The follow-up showed significant changes in MACI, even at 60 months, allowing for useful long-term MR evaluations.

Ulnar-sided wrist pain. II. Clinical imaging and treatment

Pain at the ulnar aspect of the wrist is a diagnostic challenge for hand surgeons and radiologists due to the small and complex anatomical structures involved. In this article, imaging modalities including radiography, arthrography, ultrasound (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography are compared with regard to differential diagnosis. Clinical imaging findings are reviewed for a more comprehensive understanding of this disorder. Treatments for the common diseases that cause the ulnar-sided wrist pain including extensor carpi ulnaris (ECU) tendonitis, flexor carpi ulnaris (FCU) tendonitis, pisotriquetral arthritis, triangular fibrocartilage complex (TFCC) lesions, ulnar impaction, lunotriquetral (LT) instability, and distal radioulnar joint (DRUJ) instability are reviewed.