Applicability of Cameriere's third molar maturity index on orthopantomograms and computed tomography scans from a French population

Cameriere developed a method on orthopantomograms (OPG) to assess adult age of 18 years based on the relationship between age and the third molar maturity index I3M. The aim of this study was to evaluate whether Cameriere's method could be applied to computed-tomography scans (CT-scans) from a population of French juveniles and young adults and compare the results obtained from OPG of the same individuals. Our sample comprised 200 examinations that had been performed at the radiological department of a French University hospital between 2007 and 2020. Each patient had received an OPG and a cranial CT scan for medical purposes, and we used a similar adaptation of I3M based on OPG to determine the I3M based on CT scans. Due to exclusion criteria, our final sample comprised 71 OPGs and 63 CT scans. Based on the 71 OPGs, there was concordance between chronological age and estimated age, with a sensitivity of 78.57%, a specificity of 89.47%, and a misclassified rate of 18.03% based on tooth 38, and a sensitivity of 78.79%, a specificity of 91.67%, and a misclassified rate of 17.78% based on tooth 48. Our results based on CT scans presented concordance between chronological age and estimated age for tooth 38 described by a sensitivity of 77.78%, a specificity of 94.12%, and a misclassified rate of 16.98%. The concordance between chronological age and estimated age based on 48 had a sensitivity of 75.00%, a specificity of 93.75%, and a misclassified rate of 19.23%. The > 90% ICC indicate an excellent similarity between measurements of teeth 38 and 48 based on OPGs and CT scans. This study has revealed the applicability of the Cameriere's method to calculate the I3M based on CT scans from a French population. The results based on CT scans are similar to results based on OPGs from the same individuals.

Sacroiliac joint MRI for diagnosis of ax-SpA: algorithm to improve the specificity of the current ASAS MRI criteria

OBJECTIVE

To compare sacroiliac joint (SIJ) lesions on MRI in women with versus without axial spondyloarthritis (ax-SpA) and establish an algorithm to determine whether such lesions are due to ax-SpA.

METHODS

This retrospective comparative study assessed bone marrow edema (BME), sclerosis, erosions, osteophytes, and ankylosis at the SIJ in two groups of women, one with and another without ax-SpA. Sensitivity and specificity were calculated for combinations/characteristics of lesions, using rheumatologists' assessment with assessment of spondyloarthritis international society (ASAS) criteria as the gold standard for diagnosis of ax-SpA.

RESULTS

Compared to women without ax-SpA, women with ax-SpA had more BME (61% vs 17%, p < 0.001), sclerosis (40% vs 22%, p < 0.001), erosions (35% vs 5%, p < 0.001), and ankylosis (2% vs 0%, p = 0.007), but less osteophytes (5% vs 33%, p < 0.001). The ASAS MRI criteria yielded 59% sensitivity and 88% specificity, while a new algorithm achieved 56% sensitivity and 95% specificity using the following criteria: no osteophytes at the SIJ and either (i) BME at the SIJ with at least one dimension ≥ 8 mm or (ii) at least one erosion at the SIJ.

CONCLUSIONS

We recommend the following pragmatic algorithm for MRI diagnosis of ax-SpA in women: no osteophytes at the SIJ and either (i) BME at the SIJ with at least one dimension ≥ 8 mm or (ii) at least one erosion at the SIJ. The false positive rate when using the new algorithm (3.3%) is less than half than when using the ASAS MRI criteria (7.7%); thus, its application in clinical practice could reduce overdiagnosis and prevent overtreatment of ax-SpA.

CLINICAL RELEVANCE STATEMENT

The developed algorithm has a false-positive rate that is less than half than when using the ASAS MRI criteria (3.3% vs 7.7%), thus its application in clinical practice could reduce overdiagnosis and prevent overtreatment of axial spondyloarthritis.

KEY POINTS

• Compared to women without axial spondyloarthritis (ax-SpA), women with ax-SpA had a significantly higher prevalence of bone marrow edema (BME), sclerosis, erosions, and ankylosis, but a significantly lower prevalence of osteophytes. • A new algorithm for positive ax-SpA based on sacroiliac joint MRI was developed: no osteophytes at the sacroiliac joint (SIJ) and either (i) BME at the SIJ with at least one dimension ≥ 8 mm or (ii) at least one erosion at the SIJ. • We recommend this new algorithm for diagnosis of ax-SpA in women, as it has a significantly better specificity than the assessment of spondyloarthritis international society (ASAS) MRI criteria and less than half the false positive rate; thus, its application in clinical practice could reduce overdiagnosis and prevent overtreatment of ax-SpA.

Brittle Bone Imaging: Diagnostic Procedures in Adults

This article concentrates on generalized disorders causing bone fragility. The most frequent cause of brittle bone disease is osteoporosis, only diagnosed by elimination. First, malignant osteopathy must be ruled out: fracture on metastasis or multiple myeloma, which mimics osteoporosis when presenting as diffuse demineralization. Second, patients should be screened for signs of hyperparathyroidism or osteomalacia. Much more rarely, many other pathologies can lead to brittle bone by demineralization or associated increased bone density.The radiologist needs to know the clinical context and notably the patient's age (childhood or adulthood) at discovery, and known pathologies and ongoing or previous treatments: corticotherapy, bisphosphonates, denosumab, or prior radiotherapy in the affected region. Diagnostic hypotheses are guided by the type of demineralization and the presence of lytic, mixed, or densifying areas. Lastly, the aspect and location of fractures and association with other bone abnormalities refine the diagnosis.

Forensic age assessments of alleged unaccompanied minors at the Medicolegal Institute of Montpellier: a 4-year retrospective study

Background

As many other European countries, France has to deal with a growing number of migrants including some who contend age minority entitling them to benefits and privileges reserved for children within the context of legal proceedings. In case of doubtful minority, medical examinations may be carried out to assess skeletal and dental age. Our objective was to analyse the age assessments regarding individuals of doubtful minority assertion at the Medico-legal Institute of the University Hospital of Montpellier since 2018.

Methods

Expert reports of forensic age assessments performed during the 2018–2021 period were reviewed. Demographic data and results from medical and radiological investigations based on AGFAD recommendations were recorded in each case. When available, conclusions of judicial investigations about the individuals’ actual age were collected.

Results

A total of 265 reports were compiled. Age assessments predominantly concerned males (97.7%) and the main reported country of origin was sub-Saharan Africa (80.4%). The mean reported age was 16.3 ± 0.8 years. The individual’s stated age was compatible with the age assessment in 31 cases (11.7%), while expert reports concluded that the age of majority had been reached in 131 cases (49.4%). In cases of discrepancies, the average difference between the stated and the assessed lowest possible age (= assessed minimum age) was 2.7 ± 2.3 years and 6.9 ± 3.8 years between the stated and the most probable age. Age assessments could be compared with actual ages determined by court proceedings in 27 cases, with established ages being systematically higher than the assessed minimum ages (mean difference = 4.4 ± 4.0 years). The difference between actual and stated ages ranged from 1.8 up to 18.9 years (mean difference = 6.4 ± 4.0 years). The used protocol never led to any age overestimation in this population.

Conclusion

Our study reinforces the relevance of AGFAD recommendations for forensic age assessment and calls for the harmonization of practices based on this methodology in the European countries.

Injury characteristics, initial clinical status, and severe injuries associated with spinal fractures in a retrospective cohort of 506 trauma patients

BACKGROUND

Our aim was to describe the characteristics of vertebral fractures, the presence of associated injuries, and clinical status within the first days in a severe trauma population.

METHODS

All patients with severe trauma admitted to our level 1 trauma center between January 2015 and December 2018 with a vertebral fracture were analyzed retrospectively. The fractures were determined by the AO Spine classification as stable (A0, A1, and A2 types) or unstable (A3, A4, B, and C types). Clinical status was defined as stable, intermediate, or unstable based on clinicobiological parameters and anatomic injuries. Severe extraspinal injuries and emergent procedures were studied. Three groups were compared: stable fracture, unstable fracture, and spinal cord injury (SCI) group.

RESULTS

A total of 425 patients were included (mean ± SD age, 43.8 ± 19.6 years; median Injury Severity Score, 22 [interquartile range, 17-34]; 72% male); 72 (17%) in the SCI group, 116 (27%) in the unstable fracture group, and 237 (56%) in the stable fracture group; 62% (95% confidence interval [CI], 57-67%) had not a stable clinical status on admission (unstable, 30%; intermediate, 32%), regardless of the group (p = 0.38). This decreased to 31% (95% CI, 27-35%) on day 3 and 23% (95% CI, 19-27%) on day 5, regardless of the group (p = 0.27 and p = 0.25). Progression toward stable clinical status between D1 and D5 was 63% (95% CI, 58-68%) overall but was statistically lower in the SCI group. Severe extraspinal injuries (85% [95% CI, 82-89%]) and extraspinal emergent procedures (56% [95% CI, 52-61%]) were comparable between the three groups. Only abdominal injuries and hemostatic procedures significantly differed significantly (p = 0.003 and p = 0.009).

CONCLUSION

More than the half of the patients with severe trauma had altered initial clinical status or severe extraspinal injuries that were not compatible with safe early surgical management for the vertebral fracture. These observations were independent of the stability of the fracture or the presence of an SCI.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Applying an immersive tutorial in virtual reality to learning a new technique

OBJECTIVE

The medical world is continuously evolving, with techniques being created or improved almost daily. Immersive virtual reality (VR) is a technology that could be harnessed to develop tools that meet the educational challenges of this changing environment. We previously described the immersive tutorial, a 3D video (filmed from the first-person point of view), displayed on a VR application. This tool offers access to supplementary educational data in addition to the video. Here we attempt to assess improvement in learning a technique using this new educational format.

MATERIAL AND METHODS

We selected a single neurosurgical technique for the study: external ventricular drainage. We wrote a technical note describing this procedure and produced the corresponding immersive tutorial. We conducted a prospective randomized comparative study with students. All participants read the technical note, and one group used the immersive tutorial as a teaching supplement. The students completed a multiple-choice questionnaire immediately after the training and again at six months.

RESULTS

One hundred seventy-six fourth-year medical students participated in the study; 173 were included in assessing the immediate learning outcomes and 72 were included at the six-month follow-up. The VR group demonstrated significantly better short-term results than the control group (P=0.01). The same trend was seen at six months.

CONCLUSION

To our knowledge, this study presents one of the largest cohorts for VR. The use of the immersive tutorial could enable a large number of healthcare professionals to be trained without the need for expensive equipment.

MRI of sacroiliac joints for the diagnosis of axial SpA: prevalence of inflammatory and structural lesions in nulliparous, early postpartum and late postpartum women

OBJECTIVES

To determine the prevalence of bone marrow oedema (BME) at the sacroiliac joint (SIJ) in early postpartum (EPP), nulliparous (NP) and late postpartum (LPP) women, and to identify factors associated with BME presence at the SIJ.

METHODS

Three groups were obtained: NP (never given birth), EPP (given birth within 12 months) and LPP (given birth more than 24 months). The primary outcome was the presence of BME and/or structural lesions (erosions, osteophytes, ankylosis and sclerosis) at the SIJ MRI.

RESULTS

BME prevalence was greater among EPP (33%) than NP (14%, p=0.001), but was not different to LPP (21%, p=0.071). The Assessment of SpondyloArthritis international Society (ASAS) MRI criteria for sacroiliitis were positive in 75%, 71% and 80%, respectively, of EPP, NP and LPP women with BME. EPP (38%) had similar prevalence of sclerosis than LPP (28%, p=0.135), but greater than NP (18%, p=0.001). Lastly, EPP (28%) had similar prevalence of osteophytes than LPP (42%) and NP (27%), although there was a difference between LPP and NP (p=0.006).

CONCLUSIONS

EPP have higher BME prevalence at the SIJ than NP, EPP tend to have higher BME prevalence compared with LPP and BME presence decreases with time from delivery. Three-quarters of women with BME at the SIJ had a positive ASAS MRI criteria for sacroiliitis, indicating that BME presence as the main criterion for a positive diagnosis can lead to false-positive results. SIJ MRIs should not be interpreted in isolation, since age, time from delivery and other factors may outweigh the pertinence of MRI findings. Trial registration number NCT02956824.

Value of CT to detect radiographically occult injuries of the proximal femur in elderly patients after low-energy trauma: determination of non-inferiority margins of CT in comparison with MRI

PURPOSE

To determine the margins of non-inferiority of the sensitivity of CT and the sample size needed to test the non-inferiority of CT in comparison with MRI.

MATERIALS AND METHODS

During a 2-year period, elderly patients with suspected radiographically occult post-traumatic bone injuries were investigated by CT and MRI in two institutions. Four radiologists analyzed separately the CT and MRI examinations to detect post-traumatic femoral injuries. Their sensitivities at CT (SeCT) and MRI (SeMRI) were calculated with the reference being a best valuable comparator (consensus reading of the MRI and clinical follow-up). ROC analysis followed by an exact test (Newcombe's approach) was performed to assess the 95% confidence interval (CI) for the difference SeCT-SeMRI for each reader. A sample size calculation was performed based on our observed results by using a one-sided McNemar's test.

RESULTS

Twenty-nine out of 102 study participants had a post-traumatic femoral injury. SeCT ranged between 83 and 93% and SeMRI ranged between 97 and 100%. The 95% CIs for (SeCT-SeMRI) were [- 5.3%, + 0.8%], (p^R1 = 0.1250), [- 4.5%; + 1.2%] (p^R2 = 0.2188), [- 3.4%; + 1.1%] (p^R3 = 0.2500) to [- 3.8%; + 1.6%] (p^R4 = 0.3750) according to readers, with a lowest limit for 95% CIs superior to a non-inferiority margin of (- 6%) for all readers. A population of 440 patients should be analyzed to test the non-inferiority of CT in comparison with MRI.

CONCLUSION

CT and MRI are sensitive for the detection of radiographically occult femoral fractures in elderly patients after low-energy trauma. The choice between both these modalities is a compromise between the most available and the most sensitive technique.

KEY POINTS

• The sensitivity of four separate readers to detect radiographically occult post-traumatic femoral injuries in elderly patients after low-energy trauma ranged between 83 and 93% at CT and between 97 and 100% at MRI according to a best valuable comparator including MRI and clinical follow-up. • CT is a valuable alternative method to MRI for the detection of post-traumatic femoral injuries in elderlies after low-energy trauma if a 6% loss in sensitivity can be accepted in comparison with MRI. • The choice between CT and MRI is a compromise between the most available and the most sensitive technique.

Whole-body MRI to assess bone involvement in prostate cancer and multiple myeloma: comparison of the diagnostic accuracies of the T1, short tau inversion recovery (STIR), and high b-values diffusion-weighted imaging (DWI) sequences

PURPOSE

To compare the diagnostic accuracy of whole-body T1, short tau inversion recovery (STIR), high b-value diffusion-weighted imaging (DWI), and sequence combinations to detect bone involvement in prostate cancer (PCa) and multiple myeloma (MM) patients.

MATERIALS AND METHODS

We included 50 consecutive patients with PCa at high risk for metastasis and 47 consecutive patients with a histologically confirmed diagnosis of MM who received whole-body MRI at two institutions from January to December 2015. Coronal T1, STIR, and reconstructed coronal high b-values DWI were obtained for all patients. Two musculoskeletal radiologists read individual sequences, pairs of sequences (T1-DWI, T1-STIR, and STIR-DWI), and all combined (T1-STIR-DWI) to detect bone involvement. Receiver operating characteristic curve analysis was used to assess diagnostic performance according to a "best valuable comparator" combining baseline and 6-month imaging and clinical and biological data. Interobserver agreement was calculated.

RESULTS

Interobserver agreement for individual and combined MRI sequences was very good in the PCa group and ranged from good to very good in the MM group (0.76-1.00). In PCa patients, T1-DWI, T1-STIR, and T1-STIR-DWI showed the highest performance (sensitivity = 100% [95% CI = 90.5-100%], specificity = 100% [75.3-100%]). In MM patients, the highest performance was achieved by T1-STIR-DWI (sensitivity = 100% [88.4-100%], specificity = 94.1% [71.3-100%]). T1-STIR-DWI significantly outperformed all sequences (p < 0.05) except T1-DWI (p = 0.49).

CONCLUSION

In PCa patients, a combination of either T1-DWI or T1-STIR sequences is not inferior to a combination of three sequences to detect bone metastases. In MM, T1-STIR-DWI and T1-DWI had the highest diagnostic performance for detecting bone involvement.

KEY POINTS

• The sequences used in Whole Body MRI studies to detect bone involvement in prostate cancer and myeloma were evaluated. • In prostate cancer, any pairwise combinations of T1, STIR, and DWI have high diagnostic value. • In myeloma, the combinations T1-STIR-DWI or T1-DWI sequences should be used.

MRI for diagnosis of axial spondyloarthritis: major advance with critical limitations 'Not everything that glisters is gold (standard)'

Recognition of axial spondyloarthritis (SpA) remains challenging, as no unique reference standard is available to ascertain diagnosis. Imaging procedures have been used for long in the field, in particular pelvic radiography, to capture structural changes evocative of sacroiliitis, the key feature in SpA. The introduction of MRI of the sacroiliac joints (SIJs) has led to a major shift in recognition of the disorder. MRI has been shown to detect the initial inflammatory processes, in particular osteitis depicted by bone marrow oedema, even in patients having not yet developed structural lesions. In addition, MRI has revealed a previously under-recognised very early clinical phase of the disease where patients have symptomatic axial involvement, but no structural changes. However, what constitutes a ‘positive MRI’ in SpA remains controversial, since both sensitivity and specificity show limitations, and interpretation of MRI lesions in daily practice is critically dependent on the clinical context. There is growing evidence that integration of the assessment of structural changes on dedicated T1 weighted-sequences on MRI may enhance diagnostic utility. The performance of MRI in detecting structural lesions in the SIJs may even be superior to traditional evaluation by pelvic radiography. These findings launched a debate on imaging in SpA, whether MRI, which is advancing early recognition of disease and shows superiority to detect structural changes, should replace traditional conventional radiography of the SIJs.

Coracoid bone block transfer procedure: Correlation between subscapularis volume below the bone graft and shoulder stability

INTRODUCTION

Coracoid bone graft transfer has become the gold standard in patients with recurrent anterior shoulder instability associated with bony defect. Several studies have shown that the main stabilizing component of this procedure is the sling effect by the conjoint tendon and the lower portion of subscapularis (SS). The purpose of this study was to determine whether a larger SS volume below the bone block was correlated to greater postoperative shoulder stability.

MATERIALS AND METHODS

This prospective study included a cohort of patients who underwent open coracoid bone graft transfer for post-traumatic recurrent anterior shoulder instability. Forty patients were reviewed at 2 years with a clinical and CT scan evaluation. A correlation analysis assessed the relation between the SS volume index (ratio of SS volume below the bone block to volume over the bone block) and Rowe and Walch-Duplay instability scores.

RESULTS

There exists a positive and significant correlation between SS volume index and postoperative Rowe score, r=0.37 (P=0.03). The same trend was observed for Walch-Duplay score without statistical significance. A larger inferior SS volume did not result in a limitation of external rotation, greater fatty infiltration, or malposition of the coracoid graft.

CONCLUSION

A larger SS volume below the bone block is related to greater postoperative shoulder stability. We recommend performing the split in the middle of the SS or higher instead of the junction of the superior two-thirds and inferior one-third as usually reported.

LEVEL OF EVIDENCE

III, prospective study.

Interest in the glenoid hull method for analyzing humeral subluxation in primary glenohumeral osteoarthritis

BACKGROUND

Posterior humeral subluxation is the main cause of failure of total shoulder arthroplasty. We aimed to compare humeral head subluxation in various reference planes and to search for a correlation with retroversion, inclination, and glenoid wear.

MATERIALS AND METHODS

We included 109 computed tomography scans of primary glenohumeral osteoarthritis and 97 of shoulder problems unrelated to shoulder osteoarthritis (controls); all computed tomography scans were reconstructed in the anatomic scapular plane and the glenoid hull plane that we defined. In both planes, we measured retroversion, inclination, glenohumeral offset (Walch index), and scapulohumeral offset.

RESULTS

Retroversion in the scapular plane (Friedman method) was lower than that in the glenoid hull plane for controls and for arthritic shoulders. The threshold of scapulohumeral subluxation was 60% and 65% in the scapular plane and glenoid hull plane, respectively. The mean upward inclination was lower in the scapular plane (Churchill method) than in the glenoid hull plane (Maurer method). In the glenoid hull plane, 35% of type A2 glenoids showed glenohumeral offset greater than 75%, with mean retroversion of 25.6° ± 6° as compared with 7.5° ± 7.2° for the "centered" type A2 glenoids (P < .0001) and an upward inclination of -1.4° ± 8° and 6.3° ± 7° (P = .03), respectively. The correlation between retroversion and scapulohumeral offset was r = 0.64 in the glenoid hull plane and r = 0.59 in the scapular plane (P < .05).

CONCLUSION

Measurement in the glenoid hull plane may be more accurate than in the scapular plane. Thus, the glenoid hull method allows for better understanding type B3 of the modified Walch classification.

Prevalence and topographic distribution of spinal inflammation on MR imaging in patients recently diagnosed with axial spondyloarthritis

OBJECTIVE

The primary goal of this study was to determine the prevalence and topographic distribution of spinal lesions in lower thoracic and lumbar spine on magnetic resonance imaging (MRI) in patients with recently diagnosed with spondyloarthritis. The secondary goal was to identify variables associated with vertebral patterns consistent with spondyloarthritis on MRI.

PATIENTS AND METHODS

A total of 112 HLA-B27 positive patients with recently diagnosed spondyloarthritis were retrospectively included. There were 70 women and 42 men, with a mean age of 41 years±12 (SD) (range: 17-70years). Mean symptom duration was 1year (range: 0-7years). MRI examinations of sacroiliac joints and thoracolumbar spine were reviewed for the presence of bone marrow edema, chronic structural abnormalities, and vertebral patterns consistent with spondyloarthritis. Age, gender and disease duration of patients with vertebral patterns on MRI consistent with spondyloarthritis were compared with those without MRI signs of spondyloarthritis.

RESULTS

Thirty-six patients (32.1%) showed spinal patterns of spondyloarthritis, including 16 patients (14.3%) with no associated inflammatory sacroiliitis. Posterior inflammatory lesions were present in 20.5% of patients. Posterior spinal inflammatory lesions were significantly associated with vertebral corner inflammatory lesions (P=0.03). There were no differences in age, sex or mean duration of symptoms between the two groups of patients.

CONCLUSION

Spinal involvement is observed in 32.1% of HLA-B27 positive patients with recently diagnosed spondyloarthritis and is not associated with sacroiliitis in 14.3%. Age, gender or symptom duration are not associated with spinal involvement on MRI.

Prevalence and characteristics of intravertebral enhancement on contrast-enhanced CT scans in cancer patients

STUDY DESIGN

This was a single center, retrospective observational study.

OBJECTIVE

to investigate-in a cancer population-the prevalence and hallmarks of intravertebral enhancement (IVE) detected on contrast-enhanced CT.

SUMMARY OF BACKGROUND DATA

Intravertebral enhancements secondary to iodinated contrast stagnation have been described. Cancer patients have an increased risk of perivertebral venous thrombosis or stenosis secondary to several risk factors (cancer or drug induced hypercoagulability, deterioration of venous flow linked to catheter insertion, prolonged immobilization). In case of a high density lesion identified on CT, the diagnostic choice between metastasis and contrast media within bone marrow vessels may be an issue, especially as oncologic follow-up CT scans are usually performed with contrast medium injection.

METHODS

2572 contrast-enhanced body CT scans performed in cancer patients over 3 months in the medical imaging department of a university hospital were retrospectively reviewed. IVE was sought when paravertebral venous collateral circulation was detected and bone metastasis ruled out and classified as linear or nodular. Their locations within vertebra, their relation to the injection side and the predominant collateral venous network side were evaluated.

RESULTS

Sixty-seven (2.8%) patients had a collateral paravertebral venous system and among them 21 had IVE (37%). There were 208 IVE locations involving 75 vertebrae. 199 IVE were linear-shaped (95.7%) and 9 nodular-shaped (4.3%). 80.8% were located between C6 and T4. 88.9% were localized in the vertebral body. 73.1% were located medially or ipsilateral to the injection side.

CONCLUSION

Intravertebral enhancement is found in 37% of the patients with paraspinal collateral venous circulation when a CT scan is performed for cancer. The ipsilateral or medial position of the IVE relative to the injection side and the side of the dominant perivertebral venous system, and the possibility of connecting the IVE to a paravertebral vein may be in favor of vascular opacification.

Imaging of tumors and tumor-like lesions of the knee

Tumors and tumor-like lesions of the knee are common conditions. Because the synovial membrane covers a large part of the knee, tumors and tumor-like lesions of the knee are mostly synovial. Magnetic resonance imaging (MRI) plays a major role in the assessment and characterization of these lesions. However, the diagnostic approach of these lesions must be performed systematically. First, the lesion must be precisely located, and then the anatomical structure involved must be determined. Finally, clinical background that includes the age of the patient, frequency of the disease and, if any, associated signs as well as MRI characteristics must be analyzed. In this review, we describe the anatomy of the knee and its compartments and provide a description of the main tumors and tumor-like lesions of the knee. We present a diagnostic approach based on the location within the knee of the lesions and the anatomical structures involved.

Adipose Mesenchymal Stromal Cell-Based Therapy for Severe Osteoarthritis of the Knee: A Phase I Dose-Escalation Trial

: Osteoarthritis (OA) is the most widespread musculoskeletal disorder in adults. It leads to cartilage damage associated with subchondral bone changes and synovial inflammation, causing pain and disability. The present study aimed at evaluating the safety of a dose-escalation protocol of intra-articular injected adipose-derived stromal cells (ASCs) in patients with knee OA, as well as clinical efficacy as secondary endpoint. A bicentric, uncontrolled, open phase I clinical trial was conducted in France and Germany with regulatory agency approval for ASC expansion procedure in both countries. From April 2012 to December 2013, 18 consecutive patients with symptomatic and severe knee OA were treated with a single intra-articular injection of autologous ASCs. The study design consisted of three consecutive cohorts (six patients each) with dose escalation: low dose (2 × 10(6) cells), medium dose (10 × 10(6)), and high dose (50 × 10(6)). The primary outcome parameter was safety evaluated by recording adverse events throughout the trial, and secondary parameters were pain and function subscales of the Western Ontario and McMaster Universities Arthritis Index. After 6 months of follow-up, the procedure was found to be safe, and no serious adverse events were reported. Four patients experienced transient knee joint pain and swelling after local injection. Interestingly, patients treated with low-dose ASCs experienced significant improvements in pain levels and function compared with baseline. Our data suggest that the intra-articular injection of ASCs is a safe therapeutic alternative to treat severe knee OA patients. A placebo-controlled double-blind phase IIb study is being initiated to assess clinical and structural efficacy.

SIGNIFICANCE

Although this phase I study included a limited number of patients without a placebo arm, it showed that local injection of autologous adipose-derived stem cells was safe and well tolerated in patients with knee osteoarthritis. This study also provides encouraging preliminary evidence of efficacy. Larger and controlled long-term studies are now mandatory to confirm whether this new strategy of cell therapy can improve pain and induce structural benefit in osteoarthritis.

Unknown Tendons, Muscles and Nerves of the Shoulder: Proposal for a Standardized Ultrasound-guided Examination, a "mini GEL" Experience

Thanks to its excellent spatial resolution and dynamic aspect, ultrasound of the shoulder allows an optimal evaluation of tendon, muscle and nerve' structures in shoulder pain. Through this article and owing to inter-observer reproducibility, we will describe an ultrasound standardized protocol (posterior, anterior, global plane) in basic first ultrasounds (ie without tendon abnormality of the supra/infra spinatus, the biceps and subscapularis).

Assessment of MRI abnormalities of the sacroiliac joints and their ability to predict axial spondyloarthritis: a retrospective pilot study on 110 patients

OBJECTIVE

To assess sacroiliac joint (SIJ) modifications on MRI and their ability to predict axial spondyloarthritis (SpA) with the purpose of identifying parameters for future prospective studies.

METHODS

Retrospective study was carried out of 110 consecutive patients referred for SIJ MRI with coronal, axial short TI inversion recovery (STIR), and axial T1 sequences over 6 months. Factors associated with SpA, including MRI SIJ modifications (fat deposition, structural abnormalities on T1-weighted images, and bone marrow edema [BME] on STIR sequences) and age were explored using multivariate logistic regression. The reference diagnosis was made 1-1.5 years later based on clinical, radiological, and biological findings, according to Assessment of SpondyloArthritis International Society (ASAS) criteria.

RESULTS

Twenty-eight patients were diagnosed with SpA (female/male: 19/9, age 41 ± 13 years). Abnormal findings were found in up to 21 % of patients without SpA (including 11 % with BME), versus 64 % of SpA patients (50 % with BME). A threshold age of 42.6 years was found to discriminate SpA patients (ROC AUC: 0.71, 95 % CI: 0.59-0.81). BME location in the sacral (OR: 7.07 [1.05, 47.6], p = 0.044) and both sacral and iliac areas (OR: 36.0 [5.61, 231], p = 0.0002), as well as age (OR: 0.95 [0.92, 0.98], p = 0.0019) were found to be independent predictors of SpA. 83.6 % of patients were effectively diagnosed using BME location and patient age in a classification and regression tree (CART) algorithm (sensitivity: 61 %, specificity: 91 %, PPV: 71 %, NPV: 87 %).

CONCLUSION

The BME location combined with the patient's age (threshold 42.6 years) could help predict SpA. Further studies are required before these features can be used by radiologists to boost their confidence in reporting SIJ MRI.

Tumors of the rib

The authors propose a pictorial review illustrating the imaging features of chest wall tumors and their specific features that discusses the main differential diagnoses. This review is based on published information and on our own experience.

Bilateral ischiofemoral impingement in a patient with hereditary multiple exostoses

The skeletal anatomy of the hip provides two main locations for impingement: abnormal contact between the acetabulum and femur (femoroacetabular impingement) or between the ischium and femur (ischiofemoral impingement). We report a case of bilateral ischiofemoral impingement in a patient with hereditary multiple exostoses. The association of exostoses and femoral metaphyseal widening resulted in the narrowing of the ischiofemoral spaces. Pain was improved on the left side by resection of the ischial exostosis.

[Hip and pelvic injuries in the elderly]

Fractures of the hip and pelvis are frequent and serious injuries in elderly patients. Due to the aging population, their incidence should double by 2050. Therefore, the social and economical implications of these fractures are significant. Delay in diagnosis increases the associated morbidity and mortality. The purpose is to review the imaging features of these fractures, the imaging techniques (projections, CT) to depict them and their classification based on severity.

[Imaging of the postoperative knee: normal and pathologic findings]

Surgical management of lesions of the knee has exponentially increased over the last several years. MRI plays a major role in postoperative follow-up and evaluation of patients with residual symptoms. Familiarity with the different surgical procedures and potential complications and knowledge of normal and abnormal postoperative MRI findings are essential for evaluation of the postoperative knee. The main purpose of this article is to review the postoperative imaging features of ligaments, menisci and cartilage of the knee joint since these MRI features may lead the surgeon to consider repeat surgery.

[Imaging of knee prostheses]

The authors present a pictorial essay illustrating the different types of knee prostheses, their normal appearances, as well as the imaging features (radiographs, CT, US) of the main complications that may occur.

[Imaging of traumatic injuries of the knee]

Traumatic injuries to the knee are frequent (road or sports related accidents, falls in elderly people). The Ottawa knee rules are applied and dictate the need for additional evaluation. Some fractures are adequately assessed on plain radiographs alone whereas other fractures (tibial plateau fracture) require additional evaluation with CT. Some fractures may be occult: the significance of lipohemarthrosis (indirect sign of intra-articular fracture on the lateral radiograph with horizontal beam) must be known. Benign appearing avulsion fractures suggest the presence of underlying capsuloligamentous injuries requiring further evaluation with MRI. The imaging work-up of sprains is usually negative. MRI may show areas of bone contusion that further the understanding of the mechanism of injury, predict and confirm the presence of capsuloligamentous injuries. Angiography is performed to detect popliteal artery injuries after knee dislocation which is associated with a risk of ischemia.

[Imaging of traumatic injuries of the foot and ankle]

Traumatic injuries of the foot and ankle are frequent and constitute a true public health problem with over 6000 daily cases in France. The complex anatomy of this area and its association to other injuries in polytraumatized patients can lead to delayed diagnosis with worsened functional prognosis. Accurate diagnosis relies on good knowledge of osseous and ligamentous lesions and their associations and sometimes requires the use of additional imaging techniques including US and CT.

[Interventional sonography]

Diagnostic and therapeutic interventional procedures are rapidly expanding and, when guided by imaging, are more efficient then when performed with a blinded technique. Compared to fluoroscopy and CT, ultrasound does not utilize ionizing radiation. It can facilitate needle placement for arthrography, tenography or bursography or it can guide a variety of procedures such as aspiration, arthrocentesis, local steroid injections and needling of tendon calcifications. Technological improvements have increased the precision of ultrasound guidance and have contributed to reduce the risk of complication. Real time scanning allows simultaneous visualization of the target and of needle progression and has diminished the rate of complications, that are infrequent if the operator uses a strict sterile technique and respects the contraindications.

Imagerie ostéo-articulaire du pied diabétique

Destruction in diabetic feet is secondary to neuropathy (peripheral and autonomic nervous system) in association with microangiopathy. The loss of sensation to pain and the static trouble lead to increase the pressure in some areas and predispose to pedal skin ulceration, the precursor of osteomyelitis. Plain radiography should be the first step in the evaluation for diagnosis and follow-up. The initial patterns are nonspecific but very rapid evolution associating osteolysis, osteosclerosis and fragmentation lead to the Charcot foot. When osteomyelitis is suspected, scintigraphy with labelled white blood cells and MRI are necessary to differentiate infection from neuropathy.

Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy

BACKGROUND AND PURPOSE

Steroid periradicular infiltration is a common nonsurgical sciatic pain treatment of inconsistent efficacy. The purpose of this study was to identify factors for predicting the efficacy or failure of this procedure.

METHODS

Two hundred twenty-nine patients with lumbar radiculopathy were prospectively followed up at 2 weeks and 1 year after percutaneous periradicular steroid infiltration. The intensity of radicular pain was scored on the visual analog scale (VAS). Pain relief was classified as "excellent" when the pain was completely resolved or had diminished by 75% or more, "good" for a diminution of 50% to 74%, "fair" for a diminution of 25% to 49%, or "poor" for a diminution of less than 25% or an increase in pain.

RESULTS

The mean VAS scores were 6.5 (range, 3.1-9.5) before and 4.2 (range, 0-9.5) 2 weeks after the procedure. Pain relief was graded as excellent in 45 patients (19.7%), good in 48 patients (21%), fair in 45 patients (19.7%), and poor in 91 patients (39.7%). Cause of pain, conflict location, and pain intensity were not predictive factors of radicular pain relief, whereas the symptom duration before the procedure was highly correlated with the pain relief outcome. Patients with excellent results 2 weeks after the procedure had a mean duration of symptoms of 3.04 months (SD 3.28) versus 7.96 months (DS 9.04) in the group with poor pain relief.

CONCLUSIONS

Periradicular infiltration is a simple, safe, and effective nonsurgical procedure that should be performed quite early in the course of the illness to provide radicular pain relief, because corticosteroid infiltration is less beneficial for patients with more chronic radicular pain.

[Langherans' cell histiocytosis: a case report]

Langherans' cell histiocytosis is rare in adults. It should be considered in patients with lytic osseous lesions with sclerotic rim especially when involvement of adjacent soft tissues is present.

[Foraminal, epidural and intravertebral migration of a calcified degenerated intervertebral disk]

The authors report a case of inflammatory back pain associated with radiculopathy secondary to degenerative disk calcifications migrated within the foramen, epidural space and vertebral body. The purpose of this clinical case is to illustrate this uncommon cause of radiculopathy and avoid unnecessary invasive diagnostic procedures.