Sagittal Wrist Motion of Carpal Bones Following Intraarticular Fractures of the Distal Radius

Forty patients (mean age, 37 years) with intraarticular C2 and C3 Colles fractures were treated by open reduction, internal fixation and bone grafting. At a mean follow-up of 8 years radiocarpal and midcarpal motion was evaluated, the depth of the articular surface of the distal radius in the sagittal plane was measured and the presence of arthritis was noted. The fractures healed with a mean palmar tilt of 6°, a mean ulnar tilt of 18° and ulna variance within 1 mm of the contralateral side. The depth of the articular surface of the distal radius was 1.3 mm greater than the uninvolved side. Measurement of carpal bone angles relative to the radius in maximum flexion and extension revealed lunate extension of 23°, lunate flexion of 15°, capitate extension of 62°, capitate flexion of 40°. There was a significant correlation between articular surface depth and radiocarpal motion.

Cerebral vasculitis in a patient with hereditary complete C4 deficiency and systemic lupus erythematosus

We describe the case of a female patient with hereditary complete C4 deficiency and systemic lupus erythematosus. She had suffered from lupus nephritis in early childhood. At the age of 23 years she developed severe lupus with skin disease and life-threateningcerebral vasculitis. Her cerebral disease was unresponsiveto high-dosesteroids, intravenousimmunoglobulin, fresh frozen plasma and plasma exchange. Improvement was achieved with immunoadsorption in combination with mycophenolate mofetil. The patient made a complete recovery and is maintained in complete remission on mycophenolate and low-dose steroids.

Does MIPO of fractures of the distal femur result in more rotational malalignment than ORIF? A retrospective study

PURPOSE

Intraoperative control of rotational malalignment poses a big challenge for surgeons when using modern MIPO (minimally invasive plate osteosynthesis) techniques. We hypothesized that distal femoral fractures treated with MIPO technique are more often fixed in malrotation than those treated with open reduction internal fixation (ORIF).

METHODS

In this retrospective study, we identified 20 patients who met the inclusion criteria and agreed to take part in the study. In ten patients MIPO was applied, in the other ten ORIF was used. Mean age was 44.8 (19-71 years). Functional status was assessed using clinical scores (Harris Hip Score, WOMAC Hip, KS Score, WOMAC Knee, Kujala Score). Rotational alignment was assessed with magnetic resonance imaging and compared to the opposite leg.

RESULTS

We discovered a significant difference in the mean rotational difference between the MIPO group (14.3°) and the ORIF group (5.2°). Functionally, patients in the ORIF group outperformed patients in the MIPO group in all clinical scoring systems although no one proved to be statistically significant. MIPO technique was associated with significantly more rotational malalignment compared to ORIF in distal femur fracture fixation. However, implant failure and nonunion was more common in the ORIF group, with a revision rate of 3 versus 1 in the ORIF group. Clinical scoring did not significantly different between both groups.

CONCLUSION

Taking into account the undisputable advantages of minimally invasive surgery, improved teaching of methods to avoid malrotation as well as regular postoperative investigations to detect any malrotation should be advocated.

IGFBP7, a novel tumor stroma marker, with growth-promoting effects in colon cancer through a paracrine tumor-stroma interaction

The activated tumor stroma participates in many processes that control tumorigenesis, including tumor cell growth, invasion and metastasis. Cancer-associated fibroblasts (CAFs) represent the major cellular component of the stroma and are the main source for connective tissue components of the extracellular matrix and various classes of proteolytic enzymes. The signaling pathways involved in the interactions between tumor and stromal cells and the molecular characteristics that distinguish normal 'resting' fibroblasts from cancer-associated or '-activated' fibroblasts remain poorly defined. Recent studies emphasized the prognostic and therapeutic significance of CAF-related molecular signatures and a number of those genes have been shown to serve as putative therapeutic targets. We have used immuno-laser capture microdissection and whole-genome Affymetrix GeneChip analysis to obtain transcriptional signatures from the activated tumor stroma of colon carcinomas that were compared with normal resting colonic fibroblasts. Several members of the Wnt-signaling pathway and gene sets related to hypoxia, epithelial-to-mesenchymal transition (EMT) and transforming growth factor-β (TGFβ) pathway activation were induced in CAFs. The putative TGFβ-target IGFBP7 was identified as a tumor stroma marker of epithelial cancers and as a tumor antigen in mesenchyme-derived sarcomas. We show here that in contrast to its tumor-suppressor function in epithelial cells, IGFPB7 can promote anchorage-independent growth in malignant mesenchymal cells and in epithelial cells with an EMT phenotype when IGFBP7 is expressed by the tumor cells themselves and can induce colony formation in colon cancer cells co-cultured with IGFBP7-expressing CAFs by a paracrine tumor-stroma interaction.

Lateral cephalometric analysis of mandibular morphology: discrimination among subjects with and without temporomandibular joint disk displacement and osteoarthrosis

To assess whether in patients with temporomandibular joint (TMJ) arthralgia cephalometric variables of mandibular morphology may discriminate among the magnetic resonance (MR) imaging-based TMJ groups of 'bilateral presence of disk displacement without reduction (DDwoR) and osteoarthrosis (OA)' and 'bilateral absence of bilateral DDwoR and OA'. Bilateral MR imaging of the TMJ was performed in 45 consecutive TMJ arthralgia patients to identify individuals with the specific structural characteristics of bilateral TMJ DDwoR associated with OA. Linear and angular cephalometric measurements were taken from lateral cephalograms to apply selected criteria of mandibular morphology. A discriminant function analysis was used to investigate how cephalometric parameters discriminate among the TMJ groups of 'bilateral presence of DDwoR with OA' and 'bilateral absence of DDwoR and OA'. Ramus height (Ar-Go) and effective mandibular length (Ar-Pog) produced a significant discriminant function that predicted TMJ group membership (P < 0·001). This function correctly classified 80·2% of original and cross-validated grouped cases. This study supports the concept that cephalometric variables of mandibular morphology discriminate among subjects with and without bilateral TMJ DDwoR and OA.

Intraorbital plexiform neurofibroma in an NF-1-negative patient

A 52-year-old patient presented with an orbital swelling and exophthalmos that enlarged over a period of about 40 years. The clinical examination showed massive exophthalmos and ptosis of the right eye without diplopia. The radiological investigation (MRI, CT and ultrasound) showed an unclear intraorbital mass with erosion of the orbital floor, infraorbital rim and orbital roof. The lesion was diagnosed histologically as a plexiform neurofibroma. The patient did not present any features of neurofibromatosis type 1 (NF-1) and molecular genetic analysis was unable to uncover a pathogenic sequence alteration in the NF-1 gene. Owing to the absence of clinical and ophthalmologic symptoms and the improbability of complete removal, the patient refused surgical intervention.

[MR imaging for the evaluation of accompanying injuries in cases of distal forearm fractures in children and adolescents]

INTRODUCTION

The study was made to evaluate the role of MR imaging in pediatric distal forearm fractures by comparison with the findings of plain radiographs and MRI.

MATERIAL AND METHOD

38 patients (27 boys and 11 girls, mean age of 12 years, range 7 to 15 years) with radiographically open distal radius and ulna growth plates requiring first aid for a fracture of the distal third of the forearm, were included in this study. The fractures were diagnosed on plain radiographs and conservative treatment was performed. In 35 patients MR imaging was performed within 3 weeks after the accident and in 3 patients MRI was performed after 6 to 9 weeks because of persistent wrist pain.

RESULTS

Fifteen Salter/Harris II injuries of the radius and 1 of the ulna, 1 torus fracture of the radius and 2 of the ulna, 12 greenstick fractures of the radius and 3 of the ulna, 10 complete displaced radius fractures and 15 ulnar styloid fractures were found on plain radiographs. Twelve patients had evidence of associated triangular fibrocartilage complex (TFCC) lesions in MRI, there was no statistical correlation between TFCC lesions and fracture types, fracture dislocations or patients age (p > 0.5). One patient had an avulsion of the radioscaphocapitate ligament from the radius accompanying a greenstick fracture of the distal radius. 19 bone bruises and two radiographically occult fractures were identified. In 2 patients, a bone marrow oedema was seen in the radial epiphysis immediately adjacent to the germinal zone of the growth plate. In these patients premature physeal arrest occurred.

CONCLUSION

MRI plays an important role in the evaluation of acute pediatric wrist injuries. It allows a better evaluation of osseous lesions than plain radiographs. In our study, a tear of the triangular fibrocartilage complex accompanied distal radius fractures in 32 % of patients. Simultaneous rupture of the TFCC insertion in the fovea ulnaris and ulnar styloid fracture lead to destabilisation of the distal radioulnar joint (DRUJ).

[Distal radius fractures--aetiology, treatment and outcome]

INTRODUCTION

Distal radius fractures were investigated in a retrospective open multicenter cohort study to assess aetiology, fracture pattern and treatment modalities and their influence on subjective and objective outcome.

PATIENTS AND METHOD

Demographic data, fracture history, course of fracture healing, functional and radiological parameters and the DASH-questionnaire were collected from 18 Austrian hospitals and analysed statistically.

RESULTS

PATIENTS

n = 707, 465 (65.8 %) female, 242 (34.2 %) male. Mean age: 52 (19 - 86) years; age group 1 (19 - 39 years) 26 %, age group 2 (40 - 59 years) 41 %, age group 3 (60 years and elder) 33 %.

FOLLOW-UP

mean 5.8 (3.9 - 17) years;

HISTORY

fall 65.1 %, sports 17.4 %, traffic accidents 8.9 %, fall from great height 7.5 %; others 1.1 %. Most frequent fracture patterns according to AO: A2 (26.6 %), C2 (22.2 %), A3 (16.1 %), C1 (12.7 %); according to PE: I-2 (44.8 %), I-1 (40.0 %), III-2 (4.4 %), II-2B (4 %). There was no significant correlation between fracture pattern and age groups for both fracture classifications.

TREATMENT

57.9 % surgical, 42.1 % conservative. Radiological results: Depending on treatment, there were significant differences between the radial tilt and the palmar radial inclination, the dorsal and palmar ulnar variance and the width of the DRU-joint. DASH-questionnaire: Median 6.03 (90 - 0). There was a significant, minor positive correlation of bad results in the elderly and a minor positive correlation of bad results correlated to the palmar radial inclination as well as a minor negative correlation to the palmar DRUJ-value and the ulnar variance.

CONCLUSION

The incidence of distal radius fractures was increased in females and in patients with the age between 40 - 59 years. The most frequent cause to sustain a distal radius fracture was a simple fall. 85 % of the fractures were dislocated dorsally. The most frequent fracture type was the dorsal intraarticular. There was no specific fracture type observed to be typical for one of the age groups and surgical treatment was almost as frequent as conservative. Surgical treatment improved reconstruction of the radial tilt, palmar inclination and the DRU-joint. Subjective outcome was worse in elderly patients. The radiological changes in the DRU-joint correlated to minor DASH values.

Conjoined epigastric heteropagus twins: excision of a parasitic twin from the anterior abdominal wall of her sibling

Epigastric heteropagus twins (EHT) are an exceedingly rare form of asymmetric conjoined twins in whom the dependent twin (parasite) is attached to the right or left upper abdomen of the dominant part (autosite). Such a case observed at our institution with 34 month follow-up is presented here and the surgical technique described. A magnetic resonance imaging (MRI)-supported surgical separation of the parasite with successful closure of the abdominal wall defect of the autosite was performed. Follow-up studies showed an autosite which was alive and in optimal health. A comprehensive review including data from English and non-English literature is presented.

Condylar injury: magnetic resonance imaging findings of temporomandibular joint soft-tissue changes

Recent studies have suggested magnetic resonance imaging (MRI) as useful in the evaluation of soft-tissue changes that occur in the temporomandibular joint (TMJ) after acute condylar trauma. The aim of this study was to investigate whether MRI findings of disc displacement, capsular tear and haemarthrosis are linked to the degree of condylar injury. Nineteen patients were assigned a diagnosis of uni- or bilateral condylar fracture (n=17), or condylar contusion with a uni- or bilateral diagnosis of TMJ sprain/strain (n=2). Condylar injuries were classified as grade I (absence of condylar fracture), grade II (type I, II or III condylar fracture), and grade III (type IV, V or VI condylar fracture). Bilateral sagittal and coronal MR images were obtained immediately after injury to establish the presence or absence of disc displacement, haemarthrosis and capsular tear. The data revealed a significant relationship between the degree of condylar injury and the MRI findings of capsular tear (P=0.000) and haemarthrosis (P=0.000), and between the MRI diagnoses of capsular tear and haemarthrosis (P=0.000). There was good diagnostic agreement between the presence of grade III condylar injury and the MRI diagnoses of capsular tear (K=0.62) and haemarthrosis (K=0.60). The results suggest that degree of condylar injury is related to MRI findings of capsular tear and haemarthrosis, and that MRI to supplement diagnosis of grade III condylar injury is warranted.

Diagnostic quality of dynamic high-resolution ultrasonography of the TMJ--a pilot study

The aim of this study was to compare sensitivity, specificity, accuracy and positive and negative predictive value for high-resolution ultrasonography (HR-US) in diagnosing degenerative changes, effusion and disk displacement using magnetic resonance imaging (MRI) as a reference. Over a period of 6 months, 100 patients with TMJ disorders (200 TMJs) were investigated by an experienced radiologist with HR-US and magnetic resonance imaging (MRI). The MRI investigation showed degenerative changes in 190 joints (95%), while an effusion was found in 59 (29.5%) joints. At closed-mouth position a disc dislocation was found in 138 joints (69%) and in maximum-mouth-opening position disc dislocation was diagnosed in 76 joints (38%). In the determination of degenerative changes HR-US showed a sensitivity of 94%, a specificity of 100% and an accuracy of 94%. In the detection of effusion HR-US yielded a sensitivity of 81%, a specificity of 100% and an accuracy of 95%. In the determination of disk displacement at closed-mouth position HR-US showed a sensitivity, specificity and an accuracy of 92% each. At maximum-mouth-opening position HR-US reached a sensitivity of 86%, a specificity of 91% and an accuracy of 90%. The results of the current study imply that HR-US is a valuable diagnostic imaging method of the TMJ which can be used as an alternative method to a MRI-investigation, but is yet not able to replace it. Further studies have to be done to reduce false-negative results.

Dorsal scapholunate ligament reconstruction using a periosteal flap of the iliac crest

INTRODUCTION

To report a new technique for scapholunate ligament reconstruction, using a periosteal flap of the iliac crest.

MATERIALS AND METHODS

In 12 patients with static SL instability, a periosteal flap was harvested from the anterior portion of the iliac crest. Following repositioning of the carpals, the flap was fixed to the scaphoid and lunate between an incompletely osteotomised scale at the dorsal horn of the scaphoid and lunate. Pin fixation of the scapholunate (SL) and CL interval secured postoperative reduction for 8 weeks. A forearm plaster cast was worn for 12 weeks.

RESULTS

Eleven patients, all male, were available for follow-up at an average of 29 months. The interval between trauma and surgery averaged 15 months. The preoperative SL angle measured 77 deg, CL angle was -10 deg, and SL gap amounted to 5.2 mm. At follow-up, SL angle was 59 deg, CL angle measured -2 deg, and SL gap was 2.1 mm. SL gap, SL angle, and CL angle improved significantly from preoperative to follow-up values. According to the clinical grading system of Green and O'Brian, 6 patients scored in the excellent and good category and 5 in the fair category. Using the radiologic grading system of Gickel and Millender, 9 patients scored as excellent and good, whereas the 2 poor results were due to failure of the technique.

CONCLUSION

The technique enables reduction of the SL angle and SL gap in patients with static reducible scapholunate instability. The initial results are quite encouraging.

Reliability and temporal variation of masseter muscle thickness measurements utilizing ultrasonography

Muscle thickness may now be measured in the clinic by ultrasonography. The purpose of this study was to test (i) whether the position of the transducer on the muscle affects muscle thickness measurements and (ii) whether measurements from identical locations vary over time. Muscle thickness of one masseter muscle side was measured in each of 30 volunteers. Measurements were recorded at five different locations on the lateral surface of each muscle. Four measurement sessions were performed, and two sets of measurements were recorded at each session. Spatial position of the transducer had a clear effect on the muscle thickness measurements (P < 0.0001). Measurements made at the most upper and middle level were less and greater (P < 0.0001), respectively, than those made at the upper, lower, and most lower levels. Measurements from various positions did not differ (P > 0.05) when made at the same level. Masseter thickness measurements recorded at a given site were consistent across all of the testing sessions (P=0.575). The data suggest that reliable interpretation of longitudinal measurements of masseter thickness obtained with ultrasonography requires accurate repositioning of the transducer. Ultrasonography may be used to investigate the effect of specific treatment modalities on masseter thickness measurements.

Temporomandibular joint internal derangement: detection with 12.5 MHz ultrasonography

The purpose of this study was to determine whether 12.5 MHz ultrasonography (US) could be used to assess the presence or absence of temporomandibular joint (TMJ) internal derangement (ID). In 48 consecutive patients with TMJ disorders 192 TMJ positions were investigated by US to analyse the functional disc-condyle relationship (DCR). In order to compare the respective findings with those of a diagnostic method offering a high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards. With US showing a sensitivity of 0.58 and 0.75, and a specificity of 0.92 and 0.84 for disc displacement with and without reduction, the data revealed US to be marginal in detecting the presence, but sensitive in detecting the absence of the respective types of a TMJ ID. In addition, with a positive predictive value of 0.83 and 0.71, and a negative predictive value of 0.81 and 0.87 for disc displacement with and without reduction, the results indicate that US may be insufficient in establishing a correct diagnosis for the presence or absence of the respective types of TMJ ID. Regarding the diagnosis of absence or presence of TMJ ID, the results demonstrate high-resolution (HR)-US to be sensitive in detecting the absence, and reliable in predicting the presence of TMJ ID. In view of the fact that the 12.5 MHz US technique proved to be a reliable diagnostic aid for the detection of normal, and the prediction of abnormal DCR, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.

Temporomandibular joint osteoarthrosis diagnosed with high resolution ultrasonography versus magnetic resonance imaging: how reliable is high resolution ultrasonography?

The purpose of this study was to determine whether 12.5 MHz ultrasonography (US) could be used to assess the presence or absence of temporomandibular joint (TMJ) condylar osteoarthrosis. In 40 consecutive patients with TMJ disorders, 80 TMJs were investigated by US to analyse the condylar morphology. In order to compare the respective findings with those of a diagnostic method offering a high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards. With US showing a sensitivity of 87%, and a specificity of 20%, the data revealed US to be sensitive in detecting the presence, but insufficient in detecting the absence of osteoarthrosis. In addition, with a positive predictive value of 88%, and a negative predictive value of 18%, the results indicate that US may be valuable in diagnosing the presence, but insufficient in diagnosing the absence of osteoarthrosis. In view of the fact that the 12.5 MHz US technique proved to be a valuable diagnostic aid for the detection and prediction of abnormal condylar morphology, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.

Risk factors for temporomandibular joint pain in patients with disc displacement without reduction - a magnetic resonance imaging study

The purpose of this study was to evaluate whether the magnetic resonance (MR) imaging variables of temporomandibular joint (TMJ) internal derangement, osteoarthrosis and/or effusion may predict the presence of pain in patients with a clinical disorder of an internal derangement type (ID)-III. The relationship between TMJ ID-III pain and TMJ internal derangement, osteoarthrosis and effusion was analysed in MR images of 84 TMJs in 42 patients with a clinical unilateral diagnosis of TMJ ID-III pain. Criteria for including a TMJ ID-III pain patient were report of orofacial pain referred to the TMJ, with the presence of unilateral TMJ pain during palpation, function and/or unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ internal derangement, osteoarthrosis and effusion. Using chi-square analysis for pair-wise comparison, the data showed a significant relationship between the MR imaging findings of TMJ ID-III pain and those of internal derangement (P=0.01) and effusion (P=0.00). Of the MR imaging variables considered simultaneously in the multiple logistic regression analysis, osteoarthrosis (P=0.82) and effusion (P=0.08) dropped out as non-significant in the diagnostic TMJ pain group when compared with the TMJ non-pain group. The odds ratio that a TMJ with an internal derangement type of disk displacement without reduction might belong to the pain group was strong (2.7:1) and highly significant (P=0.00). Significant increases in risk of TMJ pain occurred with 'disk displacement without reduction in combination with osteoarthrosis' (5.2:1) (P=0.00) and/or 'disk displacement without reduction in combination with osteoarthrosis and effusion' (6.6:1) (P=0.00). The results suggest that TMJ pain is related to internal derangement, osteoarthrosis and effusion. However, the data re-emphasize the aspect that these MR imaging variables may not be regarded as the unique and dominant factors in defining TMJ pain instances.

Validation of the clinical diagnostic criteria for temporomandibular disorders for the diagnostic subgroup of degenerative joint disease

Research is needed to assess the validity of the Clinical Diagnostic Criteria for Temporomandibular Disorders (CDC/TMD). The purpose of this study was to test the reliability of the clinical diagnosis of temporomandibular joint (TMJ) degenerative joint disease (DJD) as compared with the magnetic resonance imaging (MRI) 'gold standard'. The TMJ DJD group comprised 48 joints in 24 consecutive patients who were assigned a clinical bilateral diagnosis of TMJ DJD. The TMJ non-DJD group consisted of 82 joints in 41 consecutive patients without a TMJ-related diagnosis of TMD. Bilateral sagittal and coronal MR images were obtained subsequently to establish the corresponding diagnosis of degenerative joint changes. An MRI diagnosis of osteoarthrosis (OA) was defined by the presence of flattening, subchondral sclerosis, surface irregularities, and erosion of the condyle or presence of condylar deformities associated with flattening, subchondral sclerosis, surface irregularities, erosion and osteophyte. For the CDC/TMD interpretations, the positive predictive of DJD for OA was 67%, and for the presence of degenerative joint changes 88%. The overall diagnostic agreement for DJD was 44.6% with a corresponding K-value of 0.01. Most of the disagreement was due to false-negative interpretations of asymptomatic joints. The results suggest CDC/TMD to be predictive for degenerative joint changes but insufficient for determination of OA. Patients assigned a clinical TMJ-related diagnosis of DJD may need to be supplemented by evidence from MRI to determine the presence or absence of OA.

Effect of scanning level and muscle condition on ultrasonographic cross-sectional measurements of the anterior masseter muscle

With the disadvantage of computed tomography showing cumulative biological effects and magnetic resonance imaging posing a problem in clinical availability and cost, several authors described the technique of ultrasonography to measure non-invasively local cross-sectional dimensions (LCSDs) of masseter muscle sites. However only few studies addressed the issue of 'technique-related factors for intra- and inter-observer reliability' to gain more consistent testing and diagnosis. The purpose of the present study was to determine (1) whether the scanning level and/or the muscle condition may affect LCSD measurements and (2) whether measurements made at identical levels may be reproducible. The study included 35 subjects with signs and symptoms of temporomandibular disorders. Bilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to register LCSDs of the anterior masseter muscle on three different levels. Scans were made on the relaxed and contracted muscle. Measurements were made in two sessions with a time interval of at least 5 min. Data were analysed for reproducibility by using the intra-class correlation coefficient (ICC) and the method error (ME). Scanning level and muscle condition had a significant effect on muscle measurements (P = 0.000). There was no difference in LCSD between the right and left muscle (P = 0.531). Measurements recorded at a given site were consistent across the testing sessions (P = 0.058). The scanning level with highest reproducibility was halfway between the origin and insertion (ICC = 0.92; ME = 6.2%). The data suggest that ultrasonography is a reliable method for measuring LSCDs of the anterior masseter muscle.

[Diffusion-weighted MRI--a new parameter for advanced rectal carcinoma?]

PURPOSE

To evaluate the predictive value of apparent diffusion coefficient (ADC) on therapy outcome of combined chemoradiation in patients with primary carcinoma of the rectum.

MATERIALS AND METHOD

Prior to standardized, combined, neoadjuvant chemoradiation, 16 patients with primary carcinoma of the rectum (cT3) were examined with magnetic resonance imaging (MRI). Diffusion-weighted spin echo echo-planar images (SE-EPI) and contrast-enhanced T 1 -weighted spin echo (SE) images at 1.5 Tesla were obtained. The mean ADC of the tumor region was calculated and correlated with the therapy outcome substantiated by postsurgical histopathologic staging.

RESULTS

Tumor down-staging (pT0-2) occurred in 9 patients (therapy responders) and no down-staging (pT3) in 7 patients (therapy non-responders). The mean ADC measured 0.476 +/- 0.114 x 10(-3) mm 2/s in the responder group and 0.703 +/- 0.085 x 10(-3) mm 2/s in the non-responder group. Comparison of the mean ADC between the groups reached statistical significance (p = 0.001).

CONCLUSION

The mean ADC might be a new quantitative parameter to predict therapy outcome of combined preoperative chemoradiation in patients with primary carcinoma of the rectum.

Cross-sectional characteristics of the masseter muscle: an ultrasonographic study

Cross-sections of the masseter muscle may now be measured non-invasively using ultrasonography. The purpose of the present study was to determine (1) whether the scanning level may affect cross-sectional measurements and (2) whether measurements made at identical levels may be reproducible. The study included 42 asymptomatic volunteers. Unilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to register cross-sections of the masseter muscle on five different levels. Scans were made on the relaxed and contracted muscle. Measurements were made in two sessions with a time interval of at least 5 min. Statistical analysis consisted of univariate analysis of variance for repeated measurements. Data were analysed for reproducibility by using the method error and measurement error. For the ultrsonographic measurements the main effects of the variables 'session' (P=0.0001), 'level' (P=0.0001), and 'condition' (P=0.0001) were significant. Analysis of simple session-within-level effects revealed a significant difference between the repeated measurements for the most upper level (P=0.022), the upper level (P=0.012), and the most lower level (P=0.0001) of the relaxed muscle. An additional significant effect was found for the most lower level of the contracted muscle (P=0.015). Cross-sections evaluated at the middle (method error=0.31 mm; measurement error=2.0%) and lower level (method error=0.32 mm; measurement error=2.4%) of the contracted muscle were the most reproducible. The conclusion is that ultrasonography is a reproducible method for measuring cross-sections at the middle and lower level of the contracted masseter muscle.

Validation of the clinical diagnostic criteria for temporomandibular disorders for the diagnostic subgroup - disc derangement with reduction

Research is needed to assess the validity of the clinical diagnostic criteria for temporomandibular disorders (CDC/TMD). The purpose of this study was to test the reliability of the clinical diagnosis of temporomandibular joint (TMJ) internal derangement type (ID)-I as compared with the magnetic resonance imaging (MRI) 'gold standard'. The study comprised 168 TMJs in 84 patients, who were assigned a clinical TMJ-related diagnosis of ID-I (disc displacement with reduction) in at least one TMJ. Bilateral sagittal and coronal MR images were obtained subsequently to establish the corresponding diagnosis of the disc-condyle relationship. For the CDC/TMD interpretations, the positive predictive value (PPV) of ID-I for disc displacement with reduction (DDR) was 44%, and for the presence of an ID 69%. The overall diagnostic agreement for ID-I was 47.6% with a corresponding K-value of 0.05. Most of the disagreement was the result of the false-positive interpretations of ID-I, and false-negative interpretations of an 'absence of ID'. The results suggest CDC/TMD for ID-I to be insufficient reliable for determination of ID and/or DDR. Patients assigned a clinical TMJ-related diagnosis of ID-I may need to be supplemented by evidence from MRI to determine the functional 'disc-condyle relationship'.

Magnetic resonance imaging findings of osteoarthrosis and effusion in patients with unilateral temporomandibular joint pain

The purpose of this study was to investigate the relationship between the presence of temporomandibular joint (TMJ) pain and the magnetic resonance (MR) imaging findings of osteoarthrosis (OA), and effusion. The study comprised 112 consecutive TMJ pain patients. Criteria for including a patient were report of unilateral pain near the TMJ, with the presence of unilateral TMJ pain during palpation, function, and/or unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ OA, and/or effusion. Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ pain and the MR imaging diagnoses of TMJ OA (P=0.000), and TMJ effusion (P=0.000). Further, there was a significant relationship between the MR imaging diagnosis of TMJ OA and TMJ effusion (P=0.000). Use of the Kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of TMJ OA (K=0.22), TMJ effusion (K=0.29), and TMJ 'OA and effusion' (K=0.30). The study's findings suggest that while clinical pain is correlated to TMJ-related MR imaging findings, clinical pain in and of itself, is not reliable for predicting the presence of TMJ OA and/or effusion. Validation of MR imaging diagnoses would involve the investigation of cross-sectional and longitudinal evidence to assess decisive differences in terms of prognosis and/or treatment outcome.

Ultrasonographic assessment of local cross-sectional dimensions of masseter muscle sites: a reproducible technique?

Local cross-sectional dimensions (LCSDs) of masseter muscle sites may now be measured non-invasively using ultrasonography. The purpose of the present study was to determine (i) whether the muscle site may affect LCSD measurements and (ii) whether measurements made at identical sites may be reproducible. The study included 17 patients who had signs and symptoms of temporomandibular disorders (TMD). Bilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 MHz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior, and postero-inferior sites of the masseter muscle. Measurements were made in two sessions with a time interval of at least five minutes. Data were analysed for reproducibility by using the intraclass correlation coefficient (ICC) and the method error (ME). Muscle site had no significant effect on muscle measurements (P = 0.090). Measurements from the various side-related sites did not differ significantly (P = 0.425). Measurements recorded at a given site were consistent across the testing sessions (P = 0.605). The muscle site with highest reproducibility was the medio-inferior site (ICC = 0.92; ME = 6.4%). The data suggest that ultrasonography is a reproducible method for measuring LSCDs of the masseter muscle.

Magnetic resonance imaging findings of internal derangement in temporomandibular joints without a clinical diagnosis of temporomandibular disorder

The purpose of this study was to assess the prevalences of magnetic resonance (MR) imaging findings of internal derangement (ID) in temporomandibular joints (TMJs) without a specific clinical diagnosis of temporomandibular disorder (TMD), and to investigate whether in this TMJ group the variable of pain may be linked to MR imaging findings of ID. The study comprised 109 patients, who were assigned a clinical uni- or bilateral TMJ-related diagnosis of 'absence of TMD'. Bilateral sagittal and coronal MR images were obtained subsequently to establish the prevalence of TMJ ID. An MR imaging diagnosis of ID was found in 99 (55.9%) of the 177 TMJs investigated. About 30.3% of the closed mouth-related TMJ positions characterized by disc displacement presented with anterior disc displacement, while 27.3% had anterolateral and 25.3% anteromedial disc displacement. Analysis of the data revealed the presence of TMJ pain to be associated with significantly more MR imaging diagnoses of disc displacement without reduction than disc displacement with reduction (P < 0.05), while there was no significant difference in the prevalences of ID and those of absence of ID (P > 0.05). Using chi-square analysis, no significant relationship was found between the presence of TMJ pain and the MR imaging diagnosis of TMJ ID (P=0.93). Use of the kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of ID (kappa=0.01). The results suggest TMJs with a clinical diagnosis of 'absence of TMD' to be associated with a high rate of IDs, while in these instances the clinical variable of TMJ pain may have no effect on prevalences of MR imaging diagnoses TMJ ID. The data confirm the aspect of clinical diagnostic criteria as an unreliable instrument in predicting MR imaging diagnoses of TMJ ID.

Effect of stabilization-type splints on the asymmetry of masseter muscle sites during maximal clenching

Patients with temporomandibular disorders may present with a cluster of joint and muscle disorders characterized primarily by pain, joint sounds and irregular or deviating jaw function. Maxillary stabilization-type splints represent the best standard therapy, so the purpose of this study was to evaluate changes in local maximal clenching-related asymmetry patterns of masseter muscle sites associated with the immediate 'application of splint therapy' using the diagnostic approach of high-resolution gray-scale ultrasonography. The study included 24 patients who had signs and symptoms of temporomandibular disorders. Ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior, and postero-inferior sites of the masseter muscle. To assess local maximal clenching-related muscle asymmetry patterns and to evaluate the respective effect of occluding splints, the 'absolute asymmetry index' was used, with the mean maximum muscle diameter of the respective right and left sides calculated from three consecutive measurements before and after splint insertion. Comparing the values assessed before splint insertion with those after splint insertion revealed a significant decrease in local maximal clenching-related muscle asymmetry values for the antero-inferior masseter muscle site (P < 0.05). The results of this study suggest stabilization-type splints to have a site-specific effect in the immediate reduction of local maximal clenching-related muscle asymmetries. Further studies are warranted to evaluate muscle-site specific effects in patient and non-patient groups and to relate these effects to pre-treatment variables like bite force, preferred chewing side, facial morphology and occlusion.

[Distal radius fractures and concomitant lesions. Experimental studies concerning the pathomechanism]

Since Colles (1814) first described a distal radius fracture and the publication by Dupuytren (1834), the frequency of and problems surrounding these fractures were increasingly recognised. Not only the treatment but also the formation and type of fracture were repeatedly analysed. The various theories concerning the pathomechanism led to names such as: "tear fracture", "bend fracture", "thrust fracture", "compression fracture", "snap fracture" and others. In our experimental studies we attempted to simulate the pathomechanism of distal radius fractures and present them pictorially. With the help of a materials testing machine, 63 prepared cadaver arms were hyperextended in the wrist joint until a radius fracture occurred. The concomitant lesions were registered radiologically and by dissection. Moreover, additional cadaver arms were deep-frozen and examined by means of computer tomography and cryosection according to Kathrein. Through experimental hyperextension it was possible to generate dorsal, central, and palmar types of fractures. We produced 42 dorsal, 14 central and 7 palmar fractures. Fundamentally, it seems that the fracture depends on the extent in which the carpal bones of the proximal row are pressed against the dorsal, central or palmar part of the articular surface of the distal radius. The subsequent dissection showed in 40 cases (63 %) mostly multiple concomitant lesions and in 23 cases (37 %) none of these. The reason for concomitant lesions may be the proportion of bone stability to the strength of ligaments. Most frequently (27 cases, i.e. 43 %), we found a destabilisation of the articular disk with or without a bony avulsion fragment (fracture of the ulnar styloid). We also commonly found ruptures of the interosseous ligaments between scaphoid and lunate (20 cases, i.e. 32 %) and lunate and triquetrum (11 cases, i.e. 18 %). It is difficult to apply knowledge gained from experimental studies on preserved cadaver arms clinically. There are of course no physiological reflexes and the slow fracture process must be taken into consideration. This holds true not only for concomitant lesions but also for the type of fracture. On the other hand, in these experimental studies it was possible to generate many realistic types of fractures with their concomitant lesions.

The short-term effect of stabilization-type splints on the local asymmetry of masseter muscle sites

Patients with temporomandibular disorders (TMD) may present with a cluster of joint and muscle disorders characterized primarily by pain, joint sounds and irregular or deviating jaw function. Maxillary stabilization-type splints represent the best standard therapy, so the purpose of this study was to evaluate changes in local cross-sectional dimensions (LCSD) of masseter muscle sites associated with short-term application of 'splint therapy' using the diagnostic approach of high-resolution gray-scale ultrasonography. The study included 29 patients who had signs and symptoms of temporomandibular disorders. Ultrasonographic investigation was performed with a linear (B-scan) 7.5 MHz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior and postero-inferior sites of the masseter muscle. To assess local muscle asymmetry patterns and to evaluate the respective effect of occluding splints, the 'absolute asymmetry index (AAI)' was used, with the mean maximum muscle diameter of the respective right and left sides calculated from three consecutive measurements before and after splint therapy. Comparing the pre-treatment with the 2-month follow-up values revealed a significant decrease in the overall mean asymmetry indices at the anterior (P < 0.01), medial (P < 0.05) and posterior (P < 0.05) muscle sites. There was no significant change in LCSDs at the various muscle sites (P > 0.05). The results of this study suggest stabilization-type splints to be effective in reducing local muscle asymmetries. Further studies are warranted to evaluate muscle-site specific effects in patient and non-patient groups and to relate these effects to pre-treatment variables like bite force, preferred chewing side, facial morphology and occlusion.

High-resolution ultrasonography of the TMJ: helpful diagnostic approach for patients with TMJ disorders ?

PURPOSE

The purpose of this study was to investigate patients with a clinical diagnosis of internal derangement to determine the diagnostic value of static high resolution ultrasonography (HR-US) when compared with magnetic resonance imaging (MRI).

PATIENTS

Sixty-six patients (132 temporomandibular joints [TMJs]) with a clinical diagnosis of internal derangement were investigated by HR-US and MRI.

METHODS

MRI and HR-US investigations were performed by experienced radiologists. The sonograms were done with a real-time 12-Mhz linear-array scanner. The HR-US interpretation errors were re-evaluated retrospectively by the same radiologist knowing the MRI results by comparing these with the 'prospective' and 'retrospective' diagnoses. The prospective and retrospective diagnoses were also compared with each other.

RESULTS

Eighty-seven of the 132 TMJs had a disc displacement proved by MRI in the closed-mouth position. At maximum mouth opening, 54 TMJs had a disc displacement. The prospective interpretations showed a sensitivity and specificity of 78% each, accounting for an accuracy of 78%. At maximum mouth opening, HR-US resulted in a sensitivity of 61%, a specificity of 88% and an accuracy of 77%. The retrospective interpretations yielded a sensitivity of 90%, a specificity of 84% and an accuracy of 88% in the closed-mouth position. At maximum mouth opening, HR-US showed a sensitivity of 73%, a specificity of 95% and an accuracy of 86%.

CONCLUSION

HR-US is suitable for the detection of disc displacements in the TMJ. However, further studies may be warranted to reduce the proportion of false-positive interpretations, thereby avoiding the application of unnecessary treatment.

Magnetic resonance imaging findings of internal derangement and effusion in patients with unilateral temporomandibular joint pain

OBJECTIVES

The purpose of this study was to investigate the relationship between the presence of temporomandibular joint (TMJ) pain and the magnetic resonance (MR) imaging findings of internal derangement (ID) and effusion.

STUDY DESIGN

The study was comprised of 41 consecutive patients with TMJ pain. Criteria for including a patient were report of unilateral pain near the TMJ, with the presence of unilateral TMJ pain during palpation, function, and/or unassisted or assisted mandibular opening, and the absence of a specific clinical TMJ-related diagnosis of disk displacement with or without reduction. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ ID or effusion, or both.

RESULTS

Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ pain and the MR imaging diagnoses of TMJ ID (P =.001), and TMJ effusion (P =.004). Furthermore, there was a significant relationship between the MR imaging diagnosis of TMJ ID and TMJ effusion (P =.000). Use of the kappa statistic test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of TMJ ID (kappa = 0.34), TMJ effusion (kappa = 0.32), and TMJ ID and effusion (kappa = 0.27).

CONCLUSIONS

The study's findings suggest that although clinical pain is correlated with TMJ-related MR imaging findings, clinical pain in and of itself is not reliable for predicting the presence of TMJ ID or effusion, or both. Therefore, MR imaging appears to be a warranted and necessary supplement to the clinical findings.

Temporomandibular joint internal derangement type III: relationship to magnetic resonance imaging findings of internal derangement and osteoarthrosis. An intraindividual approach

The purpose of this study was to investigate whether in patients with a clinical unilateral temporomandibular joint (TMJ)-related finding of internal derangement type (ID)-III (disk displacement without reduction) in combination with TMJ-related pain, the intraindividual variable of 'unilateral TMJ ID-III pain' may be linked to subject-related magnetic resonance (MR) imaging findings of TMJ ID, and TMJ osteoarthrosis (OA). The study comprised 48 consecutive TMJ pain patients, who were assigned a clinical unilateral TMJ pain side-related diagnosis of ID-III. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ ID and/or OA. Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ ID-III pain and the MR imaging diagnoses of TMJ ID (P=0.000) and TMJ ID type (P=0.000). There was no correlation between the clinical finding of TMJ ID-III pain and the MR imaging diagnosis of TMJ OA (P=0.217), nor between the MR imaging diagnosis of TMJ OA and that of TMJ ID (P=0.350). Regarding the diagnostic subgroups of TMJ ID, a significant relationship was found between the presence of TMJ OA and the MR imaging diagnoses of TMJ ID type(P=0.002). Use of the Kappa statistical test indicated a fair diagnostic agreement between the presence of TMJ ID-III pain and the MR imaging diagnosis of disk displacement without reduction (DDNR) (K=0.42). The results suggest that TMJ ID-III pain is related to TMJ-related MR imaging diagnoses of ID. Further, the data confirm the biological concept of 'DDNR and OA' as an underlying mechanism in the etiology of TMJ-related pain and dysfunction.

Diagnosing TMJ internal derangement and osteoarthritis with magnetic resonance imaging

BACKGROUND

The authors conducted a study to investigate the relationship between the presence of temporomandibular joint, or TMJ, pain and magnetic resonance imaging, or MRI, findings of internal derangement, or ID, and arthritis, or OA.

METHODS

The authors studied 131 consecutively seen TMJ pain patients. Their criteria for including a patient in the study were report of unilateral orofacial pain referred to TMJ and the presence of unilateral TMJ pain during palpation, function, and unassisted or assisted mandibular opening. The authors took bilateral sagittal and coronal MRIs to establish the presence or absence of TMJ ID, OA or both.

RESULTS

When the authors compared TMJ side-related data from all subjects, they found a significant relationship between the clinical findings of TMJ pain and the MRI diagnoses of TMJ ID (P = .000) and TMJ OA (P = .013). They also found a significant relationship between the MRI diagnosis of TMJ ID type and that of TMJ OA (P = .000). The authors used the kappa statistical test and found poor diagnostic agreement between the presence of TMJ pain and the MRI diagnosis of TMJ ID (kappa = 0.21), TMJ OA (kappa = 0.15), and TMJ ID and OA combined (kappa = 0.18).

CONCLUSIONS

The study's findings suggest that while clinical pain is related to TMJ-related MRI findings, the presence of clinical pain is not a reliable predictor of TMJ ID, OA or both.

CLINICAL IMPLICATIONS

Using MRI to supplement clinical findings of TMJ pain appears warranted and necessary to establish the presence or absence of TMJ ID.

Relationship between temporomandibular joint pain and magnetic resonance imaging findings of internal derangement

In terms of clinical decision-making in instances of temporomandibular disorders (TMD) and orofacial pain, there is controversy in the literature over the diagnostic significance of the temporomandibular joint (TMJ)-related variable disk-condyle relationship (DCR). The purpose of this study was to investigate whether in patients with TMJ-related pain, the variable of TMJ pain may be linked to magnetic resonance (MR) imaging findings of internal derangement (ID). The study comprised 163 consecutive TMJ pain patients. Criteria for including a patient were report of orofacial pain referred to the TMJ, and the presence of uni- or bilateral TMJ pain during palpation, during function, and/or during unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the prevalence of TMJ ID types. Analysis of the data revealed the presence of TMJ pain to be associated with significantly more MR imaging diagnoses of ID than an absence of ID (P<0.001), and disk displacement without reduction than disk displacement with reduction (P<0.001). Using chi-square analysis, the results showed a significant relationship between the presence of TMJ-related pain and the MR imaging diagnosis of TMJ ID (P=0.001), and TMJ ID type (P=0.000). Use of the Kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of ID (K=0.16). The results suggest that the clinical variable of TMJ pain may have a significant effect on the prevalences of MR imaging diagnoses of TMJ ID. The data confirm the biological concept of DCR as a diagnostic approach in patients with signs and symptoms of TMJ-related pain.

Validity of clinical diagnostic criteria for temporomandibular disorders: clinical versus magnetic resonance imaging diagnosis of temporomandibular joint internal derangement and osteoarthrosis

OBJECTIVES

Research is needed to assess the validity of clinical decision criteria for the diagnoses of temporomandibular disorders. The objective of this study was to assess the reliability of clinical diagnoses in predicting magnetic resonance imaging diagnoses of temporomandibular joint internal derangement and osteoarthrosis in a patient pain group with temporomandibular disorders.

METHODS

One clinician used the Clinical Diagnostic Criteria for Temporomandibular Disorders to classify 163 consecutive patients with temporomandibular disorders on physical diagnosis. The radiologist subsequently performed magnetic resonance imaging on 326 temporomandibular joints. Diagnostic agreement was determined for the diagnostic categories of absence of internal derangement, disk displacement with reduction, disk displacement without reduction, and osteoarthrosis.

RESULTS

Use of the Kappa statistic test indicated a poor diagnostic agreement between the clinician and the radiologist.

CONCLUSIONS

The classification system of the Clinical Diagnostic Criteria for Temporomandibular Disorders provides insufficient reliability for determination of the presence of temporomandibular joint internal derangement and osteoarthrosis. It should be supplemented by evidence from cross-sectional and longitudinal investigations to assess decisive differences in the areas of pathogenesis, treatment, and prognosis.

Temporomandibular joint pain: relationship to internal derangement type, osteoarthrosis, and synovial fluid mediator level of tumor necrosis factor-alpha

OBJECTIVES

The purpose of this study was to investigate whether patients with temporomandibular joint (TMJ)-related pain classified as capsulitis/synovitis may be linked to magnetic resonance imaging (MRI) findings of internal derangement, osteoarthrosis, or the synovial fluid aspirate findings of tumor necrosis factor-alpha (TNF-alpha) level.

STUDY DESIGN

The study comprised 23 patients with temporomandibular disorders (TMD), who had nonchronic pain (pain onset < or =6 months) and a unilateral TMJ-related diagnosis of capsulitis/synovitis. Bilateral sagittal and coronal magnetic resonance images were obtained to establish the presence or absence of internal derangement, osteoarthrosis, or both. TMJ synovial fluid aspirates were obtained from the pain and contralateral nonpain sides to determine the TNF-alpha level.

RESULTS

Comparison of the TMJ side-related data showed a significant relationship between the clinical TMD diagnosis of capsulitis/synovitis and the MRI diagnoses of TMJ internal derangement (P =.002) and of TMJ internal derangement type (P =.04). The mean TNF-alpha level in synovial fluid aspirates from TMJs assigned a clinical TMD diagnosis of capsulitis/synovitis was significantly higher than in those obtained from contralateral nonpain sides (P =.001). There was no correlation between the clinical diagnosis of capsulitis/synovitis and the MRI diagnosis of TMJ osteoarthrosis (P =.13) or between the MRI diagnosis of TMJ osteoarthrosis and that of TMJ internal derangement (P =.70) or TMJ internal derangement type (P =.33).

CONCLUSIONS

The results suggest that the TMJ pain condition of capsulitis/synovitis is related to TMJ-side specific MRI diagnoses of internal derangement and internal derangement type, and synovial fluid aspirate findings of TNF-alpha level. The data confirm the concept of elevated mediator level as a diagnostic approach for patients presenting with TMJ-related pain. MRI and synovial fluid aspirates may be used as diagnostic methods for evaluating TMJ-related pain conditions.

Effect of arthrocentesis and hydraulic distension on the temporomandibular joint disk position

OBJECTIVE

Recent studies have suggested arthrocentesis and hydraulic distension as an effective treatment modality in patients demonstrating clinical findings consistent with the diagnosis of disk displacement without reduction, normal range of motion thereby being restored and pain of the temporomandibular joint reduced. In view of the fact that only a few studies have been performed to verify the biologic concept of disk displacement without reduction as a diagnostic and therapeutic approach in patients with "closed-lock" symptoms, the purpose of this study was to investigate whether temporomandibular joint-related variable disk position might be linked to cessation of related signs and symptoms associated with the performance of arthrocentesis and hydraulic distension.

STUDY DESIGN

The study compared 15 patients, each of whom was assigned a clinical unilateral temporomandibular joint-related diagnosis of internal derangement (ID) type III (disk displacement without reduction) in combination with capsulitis/synovitis. Clinical diagnoses were made according to the Clinical Diagnostic Criteria for Temporomandibular Disorders. Bilateral sagittal and coronal magnetic resonance images were obtained immediately preoperatively and at 2-month follow-up to establish the presence or absence of associated types of ID. Temporomandibular joint-related pain, level of function, and mandibular range of motion were assessed preoperatively and the data were compared with the respective 2-month follow-up findings.

RESULTS

Comparison of the pretreatment temporomandibular joint side-related data revealed the temporomandibular joint side with an ID-III in combination with capsulitis/synovitis to be associated with significantly more magnetic resonance imaging diagnoses of ID than of an absence of ID (P <.001) and with significantly more disk displacement without reduction than disk displacement with reduction (P <.001). At the 2-month follow-up, clinical evaluation showed a significant reduction in temporomandibular joint-related pain during function (P <.001), a significant reduction in the prevalence of temporomandibular joint-related diagnoses of capsulitis/synovitis (P <.001) and ID-III (P <.01), and a significant increase in mandibular range of motion (P <.01). There was no change in the prevalence rates of associated temporomandibular joint side-related IDs.

CONCLUSIONS

The results confirm the concept of disk displacement as a diagnostic approach but not as a therapeutic approach for patients presenting with signs and symptoms of unilateral ID-III in combination with capsulitis/synovitis. In terms of clinical decision-making in temporomandibular disorder-related instances of ID, magnetic resonance imaging may be used as a diagnostic method for identifying the diagnostic validity of the variable "disk-condyle relationship."

Vascularized bone graft from the iliac crest for the treatment of nonunion of the proximal part of the scaphoid with an avascular fragment

BACKGROUND

It was hypothesized that nonunion of the proximal third of the scaphoid associated with avascular necrosis could be treated successfully with a free vascularized bone graft obtained from the iliac crest.

METHODS

Fifteen patients who had a nonunion of the proximal part of the scaphoid that had been present for an average of two years and three months (range, nine months to seven years) were managed with use of a free vascularized bone graft obtained from the iliac crest. Avascularity of the scaphoid, as assessed on preoperative radiographs, was characterized by loss of trabecular structure, collapse of subchondral bone, and formation of bone cysts. The results of the procedure were assessed in terms of osseous union, pain, active motion of the wrist, and osteoarthritis. Postoperatively, vascularity of the scaphoid was evaluated with use of magnetic resonance imaging and color Doppler ultrasonography. The average duration of follow-up was six years and one month (range, two years and one month to eight years and one month).

RESULTS

Preoperatively, one patient had had pain with any movement of the wrist and fourteen had had pain after strenuous manual labor or sports activity. The average pain score, derived with use of a 10-point visual analog scale, was 2.4 points (range, 1.0 to 6.7 points). Postoperatively, union was achieved in twelve patients; six were pain-free, and six had occasional pain during strenuous manual labor or sports activity, or both. The average pain score for these twelve patients was 1.1 points (range, 0.0 to 4.2 points) on the visual analog scale. Preoperatively, osteoarthritis was limited to the region between the radial styloid process and the distal part of the scaphoid in fourteen patients and to the radioscaphoid region in one patient. Postoperatively, the degree of osteoarthritis remained unchanged in seven of the twelve patients who had union and progressed to the radioscaphoid region in five. Vascularity, as seen on the imaging studies, was restored in all twelve patients who had union. The nonunion persisted in three patients, all of whom had progressive osteoarthritis leading to carpal collapse.

CONCLUSIONS

The index procedure was successful in twelve of the fifteen patients who had a symptomatic nonunion of the proximal part of the scaphoid associated with avascular necrosis and osteoarthritis that was limited to the radioscaphoid joint.

Diagnosis of digital flexor tendon annular pulley disruption: comparison of high frequency ultrasound and MRI

PURPOSE

The objective of this study is to assess accuracy of ultrasound (US) and MRI to diagnose completely disrupted annular pulley ligaments (APL) of the flexor tendons of the fingers.

PATIENTS AND METHODS

In a prospective study 32 patients (all males 18-42 years, mean age 25 years) with clinically suspected annular pulley disruption were studied with US and MRI. As a control group we investigated 40 fingers of 10 healthy volunteers and a non-injured finger of the patients with US. A 10 MHz linear array was used for US examinations and a 1.5 Tesla unit for MRI. Imaging was performed between the accident and surgical repair within 6 weeks. Examinations were performed in an extended and forced flexed finger position.

RESULTS

Complete disruption of the APL was diagnosed by US and MRI in 14 cases confirmed by surgery. The typical sign of disruption was a marked volar displacement of the flexor tendon in the area of the torn annular pulley during forced flexion. A distance between tendon and bone at the area of the ruptured pulley of 3 mm during extension and a distance of 5 mm at flexion was typical for complete disruption.

CONCLUSION

Both diagnostic modalities, US and MRI are valuable techniques in diagnosing complete disrupted annular pulleys of the flexor tendons.

Disruption of the finger flexor pulley system in elite rock climbers

We treated 13 elite rock climbers for isolated disruptions of the pulleys of the long fingers. Diagnosis and treatment were based on the clinical finding of bow-stringing, which was confirmed by magnetic resonance imaging. Eight patients had bowstringing indicating incomplete disruption of the major pulley A2 and were treated nonoperatively (group A). Five patients showed bowstringing indicating complete disruption of the pulley A2. After failed nonoperative treatment, the pulleys were reconstructed (group B). The mechanism of injury and clinical and subjective results were evaluated. At a 31-month follow-up (range, 18 to 43 months), loss of extension in the proximal interphalangeal joint measured 5.6 degrees (range, 0 degree to 10 degrees) in group A and 4 degrees (range, 0 degree to 10 degrees) in group B. Circumference of the finger section was increased 4.2 mm in group A (range, 0 to 10 mm) and 4.8 mm in group B (range, 0 to 10 mm). Grip strength decreased 20 N in group A (range, 10 to 50 N) and 12 N in group B (range, 10 to 30 N). Four patients in group A and one in group B had bowstringing at clinical evaluation. On follow-up magnetic resonance images, bowstringing remained unchanged in group A but was reduced in all patients in group B. Good subjective results were seen in both groups.

Metallic artifacts in magnetic resonance imaging of patients with spinal fusion. A comparison of implant materials and imaging sequences

STUDY DESIGN

Devices for spinal fusion were compared with respect to their influence on magnetic resonance images. In addition, different magnetic resonance pulse sequences were evaluated to elicit their susceptibility to imaging artifacts.

OBJECTIVES

To determine the implants with the least imaging artifacts as a recommendation for the spine surgeon and to assess the best imaging strategy for the radiologist.

SUMMARY OF BACKGROUND DATA

For patients who have had surgical spinal fusion with instrumentation, magnetic resonance imaging is the most favorable diagnostic method. Unfortunately, metallic implants lead to severe degradation of image quality. These artifacts depend on the material of the implant and on the choice of the pulse sequence.

METHODS

The fusion devices were mounted on a simple plastic phantom in various combinations and were imaged on 1.5-T magnetic resonance units. Frequently used types of plates and screws made of titanium or steel in various alloys were examined on the phantom with routinely used pulse sequences. The results of these examinations were compared with those in patient studies involving the same implants as well as the same pulse sequences.

RESULTS

The least imaging artifacts were caused by titanium implants, especially when using shorter screws, wider screw placement, and thinner titanium plates. Nevertheless, there were distinct image distortions that could lead to erroneous image interpretation. The best images were acquired by spin echo (T1), turbo spin echo (T1, T2), and half Fourier single shot turbo spin echo (HASTE) sequences. Sequences containing any gradient echo components (gradient echo or turbo gradient and spin echo sequence or frequency-selective fat saturation techniques) resulted in the highest amount of image degradation.

CONCLUSION

By choosing appropriate spinal fusion devices as well as pulse sequences, postoperative magnetic resonance imaging examinations can give acceptable results, in spite of the presence of metallic implants.

The diagnostic value of ultrasonography to determine the temporomandibular joint disk position

OBJECTIVE

Temporomandibular joint (TMJ) arthrography and magnetic resonance imaging are the imaging techniques of choice in patients presenting with signs and symptoms of TMJ disorders suggesting soft tissue pathosis. With the disadvantage of arthrography as an invasive procedure and magnetic resonance imaging posing a problem in clinical availability and cost, the purpose of this study was to determine whether ultrasonography could be used to assess the presence or absence of disk displacement in patients with TMJ disorders.

STUDY DESIGN

In 17 patients, 100 TMJ positions were investigated by static and dynamic ultrasonography to analyze the disk-condyle relationship. To compare the respective findings with those of a diagnostic method offering high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards.

RESULTS

With static ultrasonography showing a sensitivity of 0.41 and a specificity of 0.70 and dynamic ultrasonography a sensitivity of 0.31 and a specificity of 0.95, the data revealed that static and dynamic ultrasonography are marginal in detecting the presence of disk displacement, but dynamic ultrasonography is sensitive in detecting the absence of disk displacement. However, with a positive predictive value of 0.61 and a negative predictive value of 0.51 for static ultrasonography, and a positive predictive value of 0.88 and a negative predictive value of 0.55 for the dynamic technique, the results indicate that both modalities are insufficient in establishing a correct diagnosis for the presence or absence of disk displacement.

CONCLUSION

In view of the fact that dynamic ultrasonography proved to be a reliable diagnostic aid for the detection of normal disk position, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.

[Rupture or stress injury of the flexor tendon pulleys? Early diagnosis with MRI]

Eighteen extreme rock climbers underwent primary clinical and MRI examination because of recent closed injuries to the flexor tendon pulleys. Follow-ups were after approximately 36 months on the average. The recent injuries, which are difficult to diagnose clinically, could be ascertained by means of MRI: This type of injury seems to occur more frequently than is currently diagnosed. Eight patients with overuse syndrome and eight patients with a short pulley rupture were treated conservatively. In two patients with long pulley rupture, the pulleys were reconstructed by means of a tendon graft using Kleinert's technique. Clinically manifest bowstringing or flexion contracture after treatment could not be ascertained on any one of the patients. All except for one showed an almost normal range of motion. By means of control MRI it was, however, possible to ascertain minor bowstringing and scars in most patients. Clinically, this partial instability manifested by lasting swelling. What was most disturbing, however, was reduced strength and the subjective feeling of insecurity during climbing.