Basic radiological assessment of synovial diseases: a pictorial essay

Suprapatellar Fat Pad Impingement due to Vascular Lesion: A Case Report

CASE

We present a fifteen-year-old adolescent boy with anterior knee pain and a palpable tender swelling in the suprapatellar region with painful terminal extension. Imaging was suggestive of a vascular lesion in the suprapatellar fat pad. He underwent arthroscopic debridement and postoperatively regained his terminal extension.

CONCLUSION

Suprapatellar fat pad impingement can rarely be due to vascular lesions or lipomatous tumors affecting the suprapatellar fat pad. If conservative treatment is unsuccessful, surgery can provide good pain relief. The tissue excised should always be sent for histopathological examination.

Lead synovitis: The important role of radiology on diagnosis and follow-up: Case report

We present the case report of a 67-year-old man with a history of a firearm injury on the left upper extremity 35 years ago. Lead synovitis and imaging features are reviewed, emphasizing radiology's crucial role in diagnosing and following this condition.

Comparison of High-Resolution Ultrasonography With Magnetic Resonance Imaging in Rheumatoid Arthritis

Objective:

The aim of this study was to examine whether high-resolution ultrasonography (HRUS) can provide information, on signs of inflammation and destruction, due to rheumatoid arthritis (RA). The focus was on the wrist joint, during early and late disease and compared the findings to those with magnetic resonance imaging (MRI).

Materials and Methods:

The study was based on 31 RA patients, with joint involvements, who were selected from those attending the outpatient rheumatology clinic. The patients completed both HRUS and MRI examinations, and their results were compared.

Results:

The HRUS and MRI images had near-perfect agreement, for detecting joint anomalies, in those RA patients. While comparing the overall performance of the HRUS and MRI studies, it was observed that HRUS was equal or nearly equal, demonstrating 90.83%, 100.0% and 94.93%, diagnostic sensitivity, specificity, and accuracy, respectively, for diagnosing RA pathologies.

Conclusion:

The early diagnosis of RA with HRUS and MRI examinations is very important, in the early treatment of RA. The HRUS examinations demonstrated a sensitive and reliable diagnostic method for assessing inflammatory activity and destructive changes in the joints of these RA patients, with HRUS findings comparable to those of MRI.

Synovial osteochondromatosis mimicking juvenile idiopathic arthritis in an adolescent: a case-based review

Synovial osteochondromatosis is an extremely rare benign condition in children and adolescents that have joint pain as a presenting manifestation. It is usually monoarticular with the knee as the most common affected joint. In this article, we describe the case of a female adolescent suffering from debilitating chronic right knee pain initially mimicking juvenile idiopathic arthritis, who was subsequently diagnosed with primary synovial osteochondromatosis. We present a review of synovial osteochondromatosis focusing on the clinical manifestations, radiographic features, histopathologic findings, and treatment, with a summarized review of pediatric patients with initial musculoskeletal presentations who were ultimately diagnosed as synovial osteochondromatosis. Although synovial osteochondromatosis is rare in children and adolescents, this condition should be included in the differential diagnosis of joint pain and may mimic juvenile idiopathic arthritis. Appropriate diagnostic radiography, including both plain radiography and magnetic resonance imaging, is necessary to accurately diagnose this condition. We also emphasize the importance of a multidisciplinary team approach to managing patients with synovial osteochondromatosis.

Surgical Treatment Patterns, Healthcare Resource Utilization, and Economic Burden in Patients with Tenosynovial Giant Cell Tumor Who Underwent Joint Surgery in the United States

Background: Tenosynovial giant cell tumors (TGCT) are rare and locally aggressive neoplasms in synovium, bursae, and tendon sheaths, which cause pain, joint dysfunction, and damage to the affected joints. Objective: To evaluate the surgical patterns and economic burden among patients with TGCT who underwent joint surgery in the United States. Methods: Patients newly diagnosed with TGCT, aged 18-64 years, who underwent joint surgery post-TGCT diagnosis were identified from the OptumHealth Care Solutions, Inc database (Q1/1999-Q1/2017). Patients were required to be continuously enrolled for ≥1 year before and ≥3 years after the first TGCT diagnosis (index date). Surgical patterns were assessed post-index. Healthcare resource utilization and associated healthcare costs, and indirect costs related to work loss in year 1, year 2, and year 3 post-index, were compared with those at baseline. Results: Of 835 eligible TGCT patients, 462 (55%) patients who had ≥1 joint surgery post-index were included. During a median follow-up of 5.7 years, 78% of patients underwent their first joint surgery in year 1 and 41% had ≥1 repeat surgery. Magnetic resonance imaging utilization was highest during baseline (46%) and declined afterward (28%, 17%, and 19% in years 1, 2, and 3, respectively). Opioids and nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy, occupational therapy, and rehabilitation services, were commonly used during baseline (45%, 40%, and 30%, respectively). More patients used opioids in year 1 vs baseline (78% vs 45%; P<0.0001), while its utilization return to baseline levels in year 2 (41%) and year 3 (42%). A similar pattern was observed for NSAIDs and physical/occupational therapy/rehabilitation services. Healthcare resource utilization and associated healthcare costs surged in year 1 and returned to baseline or lower in years 2 and 3. A similar pattern was observed for indirect costs associated with work loss. Discussion: The high proportion of patients undergoing repeat surgeries and prevalent use of opioids, NSAIDs, and physical/occupational therapy/rehabilitation services suggests an unmet medical need after surgical treatment. Conclusions: Surgical resection alone might be inadequate to control TGCT. New treatment options may complement surgery and alleviate the clinical and economic burden experienced by patients with TGCT who had received prior surgery.

Post-Traumatic Hemosiderotic Synovitis of the Knee Mimicking Pigmented Villonodular Synovitis on Magnetic Resonance Imaging (MRI) in a Child: A Case Report

Patient: Male, 13-year-old

Final Diagnosis: Post traumatic hemosiderotic synovitis

Symptoms: Knee pain • swelling and limitation in movements

Medication: —

Clinical Procedure: —

Specialty: Radiology

Osseous Pathology on Wrist Magnetic Resonance Imaging

Advanced imaging of the osseous structures of the wrist by magnetic resonance imaging (MRI) yields powerful information regarding marrow composition and overall bone structure. Various forms of pathology, both benign and malignant, have unique marrow signal abnormalities that can be easily detected by MRI given its high sensitivity to radiographically occult processes. In particular, osseous pathology can be seen in the setting of traumatic, degenerative, congenital, infectious, and neoplastic conditions. The acuity or chronicity of these conditions can often be determined by imaging to aid in appropriate therapy. A thorough understanding of the breadth of pathology and corresponding MRI appearances can allow the interpreting radiologist to formulate a concise and accurate assessment of an examination.

Feasibility of MRI in diagnosis and characterization of intra-articular synovial masses and mass-like lesions

Background

Classifications of intra-articular masses are infectious granulomatous diseases, non-infectious synovial proliferative processes (synovial chondromatosis, lipoma arborescens, rheumatoid arthritis, pigmented villonodular synovitis [PVNS]), vascular malformations, deposition disorders, neoplastic, and miscellaneous conditions. The aim of this study is to correlate the results of MRI with arthroscopy in characterization of different varieties of intra-articular synovial masses and mass-like lesions. This observational prospective study was conducted between February 2018 and August 2019. We screened 1000 routine musculoskeletal MRI examination during this period, 32 of which showed intra-articular synovial masses/mass-like lesions. The selected 32 patients (20 males and 12 females) have a mean age of 49.20 ± 2.0 years; all presented with joint swelling, pain, or difficulty of movement according to the joint affected. All patients underwent arthroscopy for histopathological correlation.

Results

The final diagnosis was synovial chondromatosis in 14 patients (43.8%), PVNS in ten patients (31.3%), and lipoma arborescens in five patients (15.6%). Synovial chondrosarcoma, synovial hematoma, and synovial ganglion cyst each in one patient (3.1%). The concordance of MRI to arthroscopy was 96.6% accuracy, 91.7% sensitivity, 99% specificity, 52.3% PPV, and 99.9% NPV.

Conclusion

Good correlation was observed between MRI and arthroscopy in diagnosis of intra-articular synovial masses/mass-like lesions.

Magnetic resonance imaging of the knee

Knee pain is frequently seen in patients of all ages, with a wide range of possible aetiologies. Magnetic resonance imaging (MRI) of the knee is a common diagnostic examination performed for detecting and characterising acute and chronic internal derangement injuries of the knee and helps guide patient management. This article reviews the current clinical practice of MRI evaluation and interpretation of meniscal, ligamentous, cartilaginous, and synovial disorders within the knee that are commonly encountered.

Efficacy of image-guided synovial biopsy

OBJECTIVE

A variety of benign and neoplastic lesions can affect the synovium, including pigmented villonodular synovitis (PVNS) and synovial chondromatosis. Prior to surgical resection, accurate characterization of synovial lesions is necessary for appropriate treatment planning. Additionally, recent advances in potential medical therapies for PVNS could decrease or eliminate the need for surgery in some cases. Such treatment options demand accurate characterization of synovial lesions prior to treatment.

METHODS AND MATERIALS

Institutional IRB approval was obtained. We identified 54 synovial biopsies performed at our institution using a comprehensive database search under ultrasound (US) or computed tomography (CT) guidance. Cases were reviewed for pre-procedure imaging, location, biopsy approach, biopsy results, post-procedure complications, and surgical pathology if synovectomy was performed.

RESULT

A total of 54 image-guided synovial biopsies were performed, 36 using CT guidance and 18 using US guidance. Six different anatomic locations were biopsied (the hip, knee, shoulder, elbow, ankle, and temporomandibular joint). Synovial tissue was obtained in 89% of cases (48/54). CT-guided biopsies had a positive yield of 86% (31/36) and US-guided biopsies had a positive yield of 94% (17/18). Surgical pathology was obtained in 30 of the cases and image-guided biopsy concordance was 90% (27/30). Of the patients taken for synovectomy, biopsy concordance of suspected neoplastic lesions was 100% (23/23). In cases of suspected neoplasm, the concordance between image-guided biopsy and surgical pathology was 96% (22/23). There were no reported complications.

CONCLUSION

Image-guided biopsy of synovial lesions is safe and effective for establishing a definitive diagnosis prior to surgical or other intervention.

Exploration and Evaluation of Therapeutic Efficacy of Drug-Free Macromolecular Therapeutics in Collagen-Induced Rheumatoid Arthritis Mouse Model

Monoclonal antibodies (mAbs) against B cell antigens are extensively used in the treatment of rheumatoid arthritis (RA). The B cell depletion therapy prevents RA symptoms and/or alleviates existing inflammation. The previously established two-step drug-free macromolecular therapeutics (DFMT) is applied in the treatment of collagen-induced rheumatoid arthritis in a collagen-induced rheumatoid arthritis mouse model. DFMT is a B cell depletion strategy utilizing Fab' fragment of anti-CD20 mAb for biorecognition and receptor crosslinking to induce B cell apoptosis. DFMT is composed from two nanoconjugates: 1) bispecific engager, Fab'-MORF1 (anti-CD20 Fab' fragment conjugated with morpholino oligonucleotide MORF1), and 2) a crosslinking (effector) component P-(MORF2)X (N-(2-hydroxypropyl)methacrylamide copolymer grafted with multiple copies of complementary morpholino oligonucleotide MORF2). The absence of Fc fragment has the potential to avoid development of resistance and infusion-related reactions. DFMT produces B cell depletion, keeps the RA score low for more than 100 days, and shows minimal cartilage and bone erosion and inflammatory cell infiltration. Further improvements will be explored to optimize DFMT strategy in autoimmune disease treatment.

Ultrasound Versus Contrast-Enhanced Magnetic Resonance Imaging for Subclinical Synovitis and Tenosynovitis: A Diagnostic Performance Study

OBJECTIVES

Radiographic manifestations of synovitis (e.g., erosions) can be observed only in the late stage of rheumatoid arthritis. Ultrasound is a noninvasive, cheap, and widely available technique that enables the evaluation of inflammatory changes in the peripheral joint. In the same way, dynamic contrast-enhanced magnetic resonance imaging (MRI) enables qualitative and quantitative measurements. The objectives of the study were to compare the sensitivity and accuracy of ultrasound in detecting subclinical synovitis and tenosynovitis with those of contrast-enhanced MRI.

METHODS

The ultrasonography and contrast-enhanced MRI findings of the wrist, metacarpophalangeal, and proximal interphalangeal joints (n=450) of 75 patients with a history of joint pain and morning stiffness between 6 weeks and 2 years were reviewed. The benefits score was evaluated for each modality.

RESULTS

The ultrasonic findings showed inflammation in 346 (77%) joints, while contrast-enhanced MRI found signs of early rheumatoid arthritis in 372 (83%) joints. The sensitivities of ultrasound and contrast-enhanced MRI were 0.795 and 0.855, respectively, and the accuracies were 0.769 and 0.823, respectively. Contrast-enhanced MRI had a likelihood of 0-0.83 and ultrasound had a likelihood of 0-0.77 for detecting synovitis and tenosynovitis at one time. The two imaging modalities were equally competitive for detecting synovitis and tenosynovitis (p=0.055).

CONCLUSION

Ultrasound could be as sensitive and specific as contrast-enhanced MRI for the diagnosis of subclinical synovitis and tenosynovitis.

Sonographic presentation of rice bodies in subacromial-subdeltoid chronic bursitis

Background

subacromial-subdeltoid chronic bursitis is one of the main causes of shoulder pain syndrome. There are various causes of shoulder pain syndrome including chronic bursitis. The sonographic appearances of chronic bursitis vary from patient to patient, depending upon the underlying cause. However, rice bodies are the rare sonographic presentation among them. Rice bodies can be associated with atypical mycobacterial tenosynovitis, bursitis, mycobacterium tuberculosis and infections, but very rarely occur in the chronic subacromial-subdeltoid bursitis. Its unique sonographic presentation makes it easy to be diagnosed confidently, but it is difficult to be recognized, interpret and distinguish from other pathologies due to its rare occurrence. It is therefore intended to present this rare and interesting sonographic presentation of chronic subacromial-subdeltoid bursitis as a case report.

Case-presentation

A 36-year-old male suffering from swelling and pain on his left shoulder for 6 months came to the clinic with Grade-3 impingement syndrome. Free-floating echogenic rice bodies were identified in the subacromial-subdeltoid bursa during ultrasound examination, which was also confirmed with Magnetic resonance imaging (MRI) and serological tests of the specimen after surgery.

Conclusion

The unique sonographic presentation of rice bodies in the chronic subacromial-subdeltoid bursitis makes it easy to be diagnosed confidently, but it is difficult to be recognized, due to its rare occurrence.

Electronic supplementary material

The online version of this article (10.1186/s13089-019-0130-y) contains supplementary material, which is available to authorized users.

Osteochondral Lesion in Diffuse Pigmented Villonodular Synovitis of the Knee

Pigmented villonodular synovitis (PVNS) is a rare benign condition that is locally aggressive and may destructively invade the surrounding soft tissues and bone causing functional loss of the joint and the limb. The knee is the most affected joint (range, 28% to 70%) but involvement of the bone is not a common feature seen at this site. We present a rare case of diffuse PVNS of the knee associated with subchondral cyst of the lateral femoral condyle. This posed a diagnostic dilemma because of bone invasion. The radiological image of synovitis was pathognomonic of PVNS but etiology of the osteolytic lesion was confirmed only on histopathology. The large osteochondral defect was eventually managed in a staged manner with bone grafting and osteochondral autograft transfer.

MR Imaging of Joint Infection and Inflammation with Emphasis on Dynamic Contrast-Enhanced MR Imaging

Contrast-enhanced MR imaging (CE-MR imaging) is recommended for diagnosis and monitoring of infectious and most inflammatory joint diseases. CE-MR imaging clearly differentiates soft and bony tissue from fluid collections and infectious debris. To improve imaging information, a dynamic CE-MR imaging sequence (DCE-MR imaging) sequence can be applied using fast T1-weighted sequential image acquisition during contrast injection. Use of DCE-MR imaging allows robust extraction of quantitative information regarding blood flow and capillary permeability, especially when dedicated analysis methods and software are used to analyze contrast kinetics. This article describes principles of DCE-MR imaging for the assessment of infectious and inflammatory joint diseases.