Structured request form in musculoskeletal radiology examinations (CONCERTO): results of an expert Delphi consensus-structured radiology request form for correct classification of patients to undergo radiological examinations of the Italian Society of Medical and Interventional Radiology (SIRM), the Italian Society of Rheumatology (SIR) and the Italian Society of Orthopedics and Traumatology (SIOT)

PURPOSE

To describe a Delphi consensus for the realization of a structured radiology request form for patients undergoing musculoskeletal imaging.

METHODS

A steering committee (four radiologists, a rheumatologist and an orthopedic surgeon) proposed a form to an expert panel (30 members, ten radiologists, ten rheumatologists and ten orthopedic surgeons). Through an online survey, the panelists voted on their level of agreement with the statements of the form using a 10-point Likert scale (1: no agreement; 10: total agreement) in a three-round process. A combination of two distinct criteria, a mean agreement level ≥ 8 and a percentage of at least 75% of responses with a value ≥ 8, was deemed as acceptable.

RESULTS

The form achieved high median ratings in all the assessed key features. During the first round, all items met the threshold to be advanced as unmodified in the next round. Additional proposed items were considered and introduced in the next round (six items in Section 1, five items in Section 2, ten items in Section 3, 11 items in Section 4, six items in Section 5, eight items in Section 6, ten items in Section 7 and eight items in Section 8). Of these items, in round 3, only six reached the threshold to be integrated into the final form.

CONCLUSIONS

Implementation of a structured radiology request form can improve appropriateness and collaboration between clinicians and radiologists in musculoskeletal imaging.

Imaging of long head biceps tendon. A multimodality pictorial essay

The aim of this is article is to provide an  imaging review of normal anatomy, most common anatomical variants and pathologies of the long head of the biceps tendon (LHB) encountered during the daily practice.

Diffusion-weighted imaging for the cellularity assessment and matrix characterization of soft tissue tumour

PURPOSE

To evaluate whether apparent diffusion coefficient (ADC) of diffusion-weighted imaging (DWI) is able to investigate the histological features of soft tissue tumours.

METHODS

We reviewed MRIs of soft tissue tumours performed from 2012 to 2015 to calculate the average ADCs. We included 46 patients (27 male; mean age: 57 years, range 12-85 years) with histologically proven soft tissue tumours (10 benign, 2 intermediate 34 malignant) grouped into eight tumour type classes. An experienced pathologist assigned a semi-quantitative cellularity score (very high, high, medium and low) and tumour grading. The t test, ANOVA and linear regression were used to correlate ADC with clinicopathological data. Approximate receiver operating characteristic curves were created to predict possible uses of ADC to differentiate benign from malignant tumours.

RESULTS

There was a significant difference (p < 0.01) in ADCs between these three groups excluding myxoid sarcomas. A significant difference was also evident between the tumour type classes (p < 0.001), grade II and III myxoid lesions (p < 0.05), tumour grading classes (p < 0.001) and cellularity scores classes (p < 0.001), with the lowest ADCs in the very high cellularity. While the linear regression analysis showed a significant relationship between ADC and tumour cellularity (r = 0.590, p ≤ 0.05) and grading (r = 0.437, p ≤ 0.05), no significant relationship was found with age, gender, tumour size and histological subtype. An optimal cut-off ADC value of 1.45 × 10^-3 mm²/s with 76.8% accuracy was found to differentiate benign from malignant tumours.

CONCLUSIONS

DWI may offer adjunctive information about soft tissue tumours, but its clinical role is still to be defined.

Perfusion pattern and time of vascularisation with CEUS increase accuracy in differentiating between benign and malignant tumours in 216 musculoskeletal soft tissue masses

INTRODUCTION

Musculoskeletal Soft Tissue Tumours (STT) are frequent heterogeneous lesions. Guidelines consider a mass larger than 5 cm and deep with respect to the deep fascia potentially malignant. Contrast Enhanced Ultrasound (CEUS) can detect both vascularity and tumour neoangiogenesis. We hypothesised that perfusion patterns and vascularisation time could improve the accuracy of CEUS in discriminating malignant tumours from benign lesions.

MATERIALS AND METHODS

216 STT were studied: 40% benign lesions, 60% malignant tumours, 56% in the lower limbs. Seven CEUS perfusion patterns and three types of vascularisation (arterial-venous uptake, absence of uptake) were applied. Accuracy was evaluated by comparing imaging with the histological diagnosis. Univariate and multivariate analysis, Chi-square test and t-test for independent variables were applied; significance was set at p<0.05 level, 95% computed CI.

RESULTS

CEUS pattern 6 (inhomogeneous perfusion), arterial uptake and location in the lower limb were associated with high risk of malignancy. CEUS pattern has PPV 77%, rapidity of vascularisation PPV 69%; location in the limbs is the most sensitive indicator, but NPV 52%, PPV 65%. The combination of CEUS-pattern and vascularisation has 74% PPV, 60% NPV, 70% sensitivity. No correlation with size and location in relation to the deep fascia was found.

CONCLUSION

US with CEUS qualitative analysis could be an accurate technique to identify potentially malignant STT, for which second line imaging and biopsy are indicated in Referral Centers. Intense inhomogeneous enhancement with avascular areas and rapid vascularisation time could be useful in discriminating benign from malignant SST, overall when the lower limbs are involved.

Magnetic resonance arthrography for femoroacetabular impingement surgery: is it reliable?

BACKGROUND

Magnetic resonance arthrography (MRA) is commonly used to demonstrate injury to the labrum and hyaline cartilage in patients with femoroacetabular impingement (FAI). The purpose of this study was to assess the diagnostic correlation between MRA and findings at arthroscopic and open surgery.

MATERIALS AND METHODS

MRA reports of 41 hips with symptomatic FAI were reviewed and compared with subsequent intraoperative findings (n = 21 surgical dislocations and n = 20 therapeutic hip arthroscopies). Each case was assessed for the presence of a cam deformity, a cartilage lesion of the femoral head, an os acetabuli, an injury to the labrum and injury to the acetabular cartilage. Results were collected prospectively in a cross-table and analysed retrospectively for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

The sensitivity, specificity, PPV and NPV in the presence of reported cam-type deformity or an os acetabuli were 100%. In the presence of cartilage lesions of the femoral head, the values were 46, 81, 55 and 73%, respectively. For labral tears, the values were 91, 86, 97 and 67%. In the presence of acetabular cartilage injuries, the values were 69, 88, 78 and 81%, respectively.

CONCLUSIONS

MRA appears to be an efficacious imaging modality in the evaluation of labral tears, cam-type impingement lesions and os acetabuli of the hip. MRA is less efficacious in the diagnosis of cartilage abnormalities in the hip, both femoral and acetabular. Researchers should focus on further improvements in imaging techniques in order to give reliable preoperative information to the surgeon.

Delay in diagnosis and treatment of soft tissue sarcomas (STS): Causes of late intervention and their role in prognosis—A prospective, multidisciplinary group study

10055

Background: STS are 1% of malignant tumors in adults. Rarity, heterogeneity in presentation, low expertise in primary care physicians (PCP) or in general hospitals, organisation problems in specialized centers may cause a delay in both diagnosis and treatment. Aim of this study is to acknowledge the barriers to optimal care and the consequences of the delay on prognosis. Methods: Patients with STS of the extremities, trunk, retroperitoneum treated and followed from 1999 to 2011 by the same multidisciplinary group were included. Time and pattern of symptoms onset, anatomic site, tumor volume, patients’ age, gender and home, interval between diagnosis and surgical treatment or neoadjuvant chemotherapy; time to start adjuvant RT or CT were considered in a univariate - multivariate analysis. Results: 449 adult patient (53% F, 47% M, median age 55 years) were followed for a median time of 116.38 months. 65.7% of STS were at the extremities, 17.6% retroperitoneal, 16.7% at the trunk wall. Median volume at diagnosis was 8 cm for trunk and extremities; 15 cm for retroperitoneum. Commonest histologies: liposarcoma. 18.2%; leiomyo 16.8%; mixofibro 13.6%. Increasing mass, pain, and abdominal disconfort were the main revealing signs of diseases. Median time of delay were: from onset of symptom to first medical visit 68 days for trunk and extremities, 82 for retroperitoneum; 104 days from symptoms to histological diagnosis; 129 days from symptoms to start of therapy. Time to surgery after definitive diagnosis was 12 days in extremities and 21 in abdomen. Adjuvant CT started 22 days after surgery for extremities, 25 in trunk, 35 in retroperitoneum. RT initiated after 78 days. Longer delay in treatment lead to worse prognosis: MS 89.95 months if delay was > 3 months; 190.40 months if wait was < 3 months (p 0.007). Conclusions: Low self consciousness of the patient; misdiagnosis or inadequate approach in general hospitals; late referral to specialized centres are 75% of the cause of wasted time. Organization problems at the referral Centre concur for 25% of delay. Guidelines implementation and educational programme among general population and PCP are necessary.

Accuracy of core-needle biopsy after contrast-enhanced ultrasound in soft-tissue tumours

OBJECTIVE

Percutaneous biopsies are gaining acceptance in the diagnosis of soft-tissue tumours. Sampling in the most representative area is not easy in sarcomas of huge dimension. We hypothesised that ultrasound (US) contrast medium could identify the representative area for focus core-needle biopsy (CNB) METHODS: This is a retrospective cohort series of 115 soft-tissue masses treated from January 2007 to November 2008. Accuracy of US-guided CNB after contrast-enhanced US (CEUS) was determined by comparing the histology of the biopsy with the definitive diagnosis in 105 surgically excised samples (42 benign, 63 malignant) and with the expected outcome in the remaining ten malignant cases not surgically treated. A myxoid component was present in 21 sarcomas (34.4%).

RESULTS

Of samples, 94.8% were adequate for diagnosis with 97.1% sensitivity and 92.5% specificity. Sensitivity and specificity in specific histopathological subgroupings were 100%, and in grading definition they were 100% and 96.8%.

DISCUSSION

US-guided CNB is safe and effective. US contrast medium depicts tumour vascular supply and identifies the representative area(s) for sampling. Sensitivity and specificity are also high in subgrouping and grading, including myxoid types. Discussion about biopsy is part of the essential multidisciplinary strategy for these tumours.

CEUS in abdominal trauma: multi-center study

The objective of this study was to evaluate the concordance of US and contrast-enhanced US (CEUS) with CT in the assessment of solid organ injury following blunt trauma. Patients underwent complete US examination, including free fluid search and solid organ analysis. CEUS followed, using low-mechanical index techniques and SonoVue. CT was performed within 1 h. Among 156 enrolled patients, 91 had one or more abnormalities (n = 107) at CT: 26 renal, 38 liver, 43 spleen. Sensitivity, specificity, and accuracy for renal trauma at baseline US were 36%, 98%, and 88%, respectively, after CEUS values increased to 69%, 99%, and 94%. For liver baseline US values were 68%, 97%, and 90%; after CEUS were 84%, 99%, and 96%. For spleen, results were 77%, 96%, and 91% at baseline US and 93%, 99%, and 97% after CEUS. Per patient evaluation gave the following results in terms of sensitivity, specificity and accuracy: 79%, 82%, 80% at baseline US; 94%, 89%, and 92% following CEUS. CEUS is more sensitive than US in the detection of solid organ injury, potentially reducing the need for further imaging. False negatives from CEUS are due to minor injuries, without relevant consequences for patient management and prognosis.

Musculoskeletal tumours: preliminary experience with perfusion MRI

PURPOSE

Our study aimed to assess the role of magnetic resonance imaging (MRI) in the characterisation of musculoskeletal tumours and to identify specific perfusion patterns for the different tumours.

MATERIALS AND METHODS

Between January 2003 and September 2005, we evaluated the conventional and perfusion MRIs of 39 patients with musculoskeletal tumours. Dynamic MRI was performed with a 1.5-T and 1.0-T MRI unit before and after the intravenous administration of contrast material, using dedicated phased-array coils appropriate for the region to be studied and fast and ultrafast consecutive sequences. Postprocessing was done on an independent workstation (Advantage Windows, GE Medical System), with Functool (GE) software, which allowed a quantitative evaluation of enhancement as a function of time. The results were compared with the histopathological diagnoses obtained by biopsy or surgery.

RESULTS

The lesions identified in the 39 patients included 23 soft tissue tumours (12 benign, 11 malignant) and 16 bone tumours (ten benign, six malignant). Comparing the time-intensity diagrams of lesions of the same histological type, we found typical enhancement patterns for some bone tumours only, especially for bone, cartilaginous, fibrohistiocytic and pseudoinflammatory lesions. No typical enhancement pattern could be detected for any of the histological types of soft tissue tumour. Analysis of the slope of the time-intensity curves has a sensitivity and specificity of 64%-58% for soft tissue tumours and 86%-67% for bone tumours in determining the biological aggressiveness of the lesions.

CONCLUSIONS

Perfusion MRI had moderate sensitivity and specificity in the differential diagnosis between lesions with high or low biological activity. Only in a few cases was it possible to find some correlation between perfusion patterns and lesion histology. The slope values should therefore be used in combination with conventional spin-echo images and other imaging and clinical data in order to narrow the field of the possible differential diagnoses and reliably predict the nature of the lesion.

Ultrasound and magnetic resonance imaging in sports-related muscle injuries

PURPOSE

The objective of this study was to evaluate the role of magnetic resonance imaging (MRI) and ultrasonography (US) in the diagnosis of traumatic muscle injuries.

MATERIALS AND METHODS

From June 2003 to June 2004, 81 football players with a history of traumatic muscle injuries to the lower limbs were examined. US was performed shortly after the trauma (from 6 to 72 h afterwards) and MRI within a maximum of 5 days.

RESULTS

MRI revealed 26 minor and 55 major traumas. MRI and US showed complete concordance in 71 patients (site, type and extent of injury). US produced ten false negative results, including six minor lesions and four major lesions. US had a sensitivity of 87.65% in the correct identification of muscle injuries; its sensitivity was 92.72% for major lesions and 76.92% for minor lesions, 57% for delayed-onset muscle soreness (DOMS), 80% for lengthenings, 83% for contractures, 84% for strains, 87.5% for mild contusions and 100% for severe contusions.

CONCLUSIONS

US is the first-line technique for examination of muscle injuries. MRI is able to reveal lesions that may be missed at US and provide a more accurate assessment of site and extent of injury.

Contrast enhanced gray-scale sonography in assessment of joint vascularity in rheumatoid arthritis: results from the IACUS study group

The purpose of this study way to assess the value of contrast enhanced gray-scale ultrasound (CEUS) in detection of vascularity in joints of patients with rheumatoid arthritis (RA) in a multicenter study of the International Arthritis Contrast Ultrasound (IACUS) study group. We assessed 113 joints in 113 patients (44 men, 69 women; mean age 51+/-14 years) with clinical diagnosis of RA. Gray-scale ultrasound (US), power Doppler US (PDUS) and CEUS, using a low mechanical index US technique, was performed. CEUS was done by bolus administration of the contrast agent SonoVue (Bracco, Milan, Italy) with a dosage of 4.8-ml SonoVue flushed with 10 ml saline. Detection of joint vascularity was performed for differentiation of active synovitis from inactive intra-articular thickening (synovitis/effusion). With the use of US and PDUS, active synovitis could be differentiated from inactive intra-articular thickening in 68/113 joints (60.1%), whereas CEUS enabled differentiation in 110/113 (97.3%) joints (p<0.0001). Thickness measurement of active synovitis was significantly improved after contrast administration (p=0.008). In conclusion, CEUS improves the differentiation of active synovitis from inactive intra-articular thickening. Since CEUS has shown an ability to improve assessment of vascularized synovial proliferation in RA affected joints, this technique may have further potential in monitoring therapy.

Osteoid osteoma: our experience using radio-frequency (RF) treatment

PURPOSE

To present the results of two years experience with a minimally invasive radio-frequency technique designed by our team in the treatment of osteoid osteoma.

MATERIALS AND METHODS

A total of 21 osteoid osteoma patients (15 males, 6 females, age range 13 to 34 yrs) were treated between January 2001 and April 2003. Localizations of the osteoid osteoma were the pelvis (n = 1), the femur (n = 12), the tibia (n = 3), the foot (n = 3), and the humerus (n = 2). All patients underwent an X-ray examination, a CT scan and a bone Scintiscan. In the initial phase, a K-wire just slightly larger than the 17G needle electrode is positioned manually at the zenith of the target area under CT guidance and using an orthopaedic drill it is inserted at the centre of the nidus. A tailor-made metal sheath is inserted on the K-wire to create a ''tunnel'' through which the needle electrode can substitute the K-wire; at the same time, the electrode needle is positioned inside the lesion. The temperature of the exposed tip of the needle is 90 degrees C and duration of hyperthermia is 6 minutes on average. Once the procedure has been completed, a scan os performed to measure the density of the treated site and this measurement is then used as an evolution index for the evaluation of the healing process during follow-up.

RESULTS

No serious complications were observed at follow-up. General anaesthesia was only required in the case with hip involvement; peripheral anaesthesia was used in all the other cases. Complete resolution of the pain was reported in all cases after a maximum of three weeks.

DISCUSSION AND CONCLUSIONS

After two years experience, we believe percutaneous RF treatment of osteoid osteoma to be the first choice technique when compared to traditional surgery due to the fact that it is almost non-invasive, quick, repeatable if need be and offers a high reduction in costs. Moreover early weight bearing is the norm and the patient is dismissed after only one day of hospitalization. The clinical results indicate a 100% success rate with complete remission of symptoms and no relapses having been reported at the time of writing for those patients who have arrived at the two year follow up (4 out of 21).

MR Arthrography: a proposal for solution optimization with lidocaine. An in vitro experience

PURPOSE

Pain on capsule distension in painful joints may affect feasibility of the MR Arthrography. We tried to overcome this limitation by adding a local anesthetic (lidocaine) to the paramagnetic contrast agent solution. We aimed at: a) investigating which contrast agent dilution provides the best signal-to-noise ratio in the SE T1 sequences; b) evaluating the effects of lidocaine on the signal intensity and on the viscosity of the solutions; assessing the viscosity of solutions containing iodinated contrast agent.

MATERIALS AND METHODS

The paramagnetic contrast agent was diluted with saline and lidocaine at various concentrations. Signal intensity was measured with a 1.5 Tesla superconductive MR unit with a dedicated head coil; we used T1-weighted spin-echo sequence. The viscosity coefficient of the solutions was analyzed and compared with that of solutions containing iodinated contrast agents (but not lidocaine).

RESULTS

Signal intensity is also unaffected by variations in the concentration of lidocaine, which does not interfere with the biphasic behavior of Gadolinium. Viscosity is scarcely affected by changes in lidocaine concentration when the paramagnetic contrast agent concentration is not changed.

CONCLUSIONS

The optimal signal-to-noise ratio in T1-weighted sequences is provided by 0.4%, contrast agent dilution but contrast agent-saline solutions, with(out) lidocaine, cannot be considered steady and signal intensity values change over time. The addition of lidocaine does not significantly influence the signal-to-noise ratio and the viscosity of the solutions. The low viscosity of the paramagnetic contrast agent appears to favor quicker spread of the solution, even in tiny defects; thanks to its anesthetic effect, lidocaine could facilitates execution of the examination in painful joints without affecting the diagnostic result.

Echocolor Power Doppler with contrast medium to evaluate vascularization in lesions of the soft tissues of the limbs

PURPOSE

Echocolor Power Doppler with contrast medium forms a non-invasive vascular image; the purpose of the study is to evaluate the effectiveness in differentiating benign and malignant tumors in the soft tissues of the limbs.

MATERIAL AND METHOD

Echocolor Power Doppler with contrast medium was used to study 80 patients with swelling in the soft tissues of the limbs: there were 54 benign lesions, 22 sarcomas, and 4 aggressive desmoid fibromatoses.

RESULTS

Were identified 4 patterns of wash-in and wash-out curves that could be correlated to the histological diagnosis: type I was present in 85% of benign lesions, type III in 91% of malignant lesions and in 3.7% of the benign ones, type II in aggressive fibromatoses, anomalous type in 4 benign lesions and 2 sarcomas; the curve was absent in 2 benign lesions.

CONCLUSIONS

Power Doppler Echocolor with contrast medium can become a useful method to be associated with traditional imaging methods in the differential diagnosis of swelling of the soft tissues of the limbs.

CT evaluation pre- and post-percutaneous ablation by radiofrequency of osteoid osteoma. Preliminary experience

PURPOSE

Evaluation of bone remanagement after treatment by thermoablation of osteoid osteoma (OO) by CT scan.

MATERIAL AND METHOD

Nine cases of OO (8 in the limbs, 1 in the pelvis) following biopsy were treated by CT-guided thermoablation. Clinical results, complications, density of tissues treated by CT scan (pre-postop, 6, 12 months) are evaluated.

RESULTS

Absence of complications, regression of pain over 2 weeks, resumption of sports activity in 1 month. Bone density after treatment increases but even after 1 year it is much lower than normal levels.

CONCLUSIONS

Bone remodeling after thermoablation of OO requires much time, the process is still visible 12 months later by CT scan. CT scan is an adequate method, not only for diagnosis and treatment, but also for follow-up, capable of evaluating in time the changes in density of the site of the lesion, which is useful for a comparison in case of postoperative pain of doubtful origin.

The integration of vascular surgical techniques with oncological surgical protocols in the treatment of soft tissue sarcomas of the limbs

Soft tissue tumors, involving the vascular bundle, require a particular surgical approach: oncological and vascular surgical techniques must be integrated in order to perform a limb-saving surgery with adequate margins. Thirty-six soft tissue sarcomas of the thigh and popliteal region were treated from June 1999 to September 2002. Nineteen cases involving the vascular bundle were analysed and placed in two groups according to imaging and clinical information: Group A, 14 patients, with tumors close to femoral vessels without adventitial infiltration, and Group B, 5 patients, with vascular infiltration. Group A was treated with vascular blunt dissection performing adventitial excision. Group B was treated with vascular "en-bloc" resection and reconstruction. Imaging and clinical information together with surgical techniques, strategies and complications were analysed in order to plan the surgical approach in neoplastic vascular bundle involvement.

A preliminary experience in the study of soft tissue superficial masses. Color-Doppler US and wash-in and wash-out curves with contrast media compared to histological result

PURPOSE

A morphological analysis of wash-in and wash-out curves was carried out to assess their significance in the evaluation of superficial masses with US after the introduction of contrast medium, and to compare the findings with the histological analysis.

MATERIALS AND METHODS

From April to December 2000 we studied 70 patients with palpable masses in different body sites. Each patient underwent US examination at baseline and after the introduction of Levovist contrast medium (Schering, Berlin, Germany), performed with an AU5 Harmonic device (Esaote Biomedica, Genoa, Italy), using linear probes with frequencies ranging from 7.5 to 13 MHz and software assessing wash-in and wash-out curves. All the patients underwent surgical excision of the mass. Histological confirmation of the nature of the mass was therefore available for all cases.

RESULTS

Out of 70 examined patients, 43 had benign and 27 had malignant lesions. In cases of dubious interpretation of ultrasound and MR imaging, color Doppler US with contrast medium and the subsequent analysis of wash-in and wash-out curves exhibited a particular curve pattern indicating the nature of the lesion.

DISCUSSION AND CONCLUSIONS

Based on the preliminary data gathered, we believe that the analysis of wash-in and wash-out curves can be useful and reliable in diagnosing an expansile soft tissue lesions. Because our study is still in its early stages and is based on a small number of cases, no conclusions can be drawn as yet but just an observation and description of data obtained.

Fibro-cartilaginous lesions of the glenoid labrum in shoulder instability: a proposed classification using sagittal-oblique arthro-MRI

PURPOSE

To propose a graded classification of lesions of the fibrocartilaginous glenoid labrum in traumatic dislocations of the shoulder, based on arthro-MRI in sagittal-oblique views.

MATERIALS AND METHODS

Seventy-one patients with histories of chronic post-traumatic shoulder instability were studied from May 2000 to May 2001. MR images were obtained using superconducting magnets operating at 1 and 1.5 Tesla, with a dedicated shoulder coil. The study was carried out in combination with arthrography, with axial sections oriented perpendicularly to the longitudinal axis of the glena, oblique coronal sections parallel to the course of the supraspinous muscle tendon and oblique sagittal sections with axis parallel to the longitudinal axis of the glena.

RESULTS

In one case an anatomical variant was found (Buford complex). In 18 patients a simple fissuration of the fibrocartilaginous glenoid labrum was found, whereas 28 patients displayed more extensive lesions affecting the middle-inferior portions of the labrum. In 15 patients the lesion extended to the middle-superior third of the glena, involving the middle glenohumeral ligament. In 9 cases, in addition to a complete lesion of the labrum, with typical "bucket-handle" appearance, a lesion of the superior and middle glenohumeral ligaments was also observed.

DISCUSSION AND CONCLUSIONS

In traumatic shoulder dislocations it is essential to provide the surgeon with precise information regarding the location, extension and degree of damage to the capsule, ligaments and especially the labrum of the glenohumeral joint. On the basis of the results obtained in the sagittal-oblique sections we propose an MR-arthrography classification dividing lesions of the fibrocartilaginous labrum into 4 grades.

Postmeniscectomy osteonecrosis

In the last few years, postmeniscectomy osteonecrosis has been reported, especially in elderly patients, with low incidence, unclear physiopathology, and without long periods of follow-up. We report a case diagnosed and followed-up for a 3-year period using magnetic resonance imaging. In the initial phase, a large area of intramedullary edema was evident; after 3 months, the edema had decreased (it was no longer evident at 1 year examination) and a clearly defined area of osteonecrosis was evident with very high signal intensity on high-contrast sequences. After 3 years, the lesion showed a degenerative cyst appearance with an osteosclerotic rim and completely disrupted cartilage.

[Ankle impingement syndrome]

PURPOSE

The ankle impingement syndrome depends on many factors (fiber or bone production changes) manifested with pain and limited range of movement of the tibiotarsal joint. We tried to classify the various causes and sites of impingement syndromes with MRI.

MATERIALS AND METHODS

A cohort of 42 selected patients underwent a 2-year orthopedic follow-up. All patients were examined with MRI using both a low field permanent dedicated magnet at 0.2 Tesla (Artoscan, Esaote Biomedica, Genoa, Italy) and a high field General Electric unit at 1.0 T; sequences and views were chosen according to the condition studied. Gd-DTPA was administered in 26/42 patients. All patients underwent arthroscopy.

RESULTS

Twenty-one patients had positive symptoms in the anterolateral region of the ankle and 14 of them had lateral changes. In 13 patients we found fibrous tissue (meniscoid lesion) or hypertrophy of the synovial tissue. An intra-articular body was observed in one patient. An osteophyte was found in 5 patients at the level of the anterior margin of the tibia, with the presence of reactive synovial tissue. Three of 18 patients with posterior pain had a traumatic injury of the posterior exterior tubercle of the astragalus, 7 had a fracture of the os trigonum and 2 had small sclerotic foci formations in calceneal site; chondropathy with sclerosis of subchondral bone was diagnosed in 2 patients. Posterior bone impingement was observed in the remaining 4 patients. Two patients had synovial impingement in posterolateral site. A posterior plica synovialis was seen in 1 patient. Fibrotic-scar tissue was observed in one case, in the subtalus region (impingement synovialis subtalaris). The administration of intra-articular Gd-DTPA provided better definition of the fibrous tissue and the intra-articular free bodies. Modest vascular enhancement of the tissues was seen in 9 of 8 patients receiving the contrast agent. In the other two cases, where signal tissue was low, no signal enhancement was observed after the contrast agent administration.

DISCUSSION

Based on integrated MR, clinical and arthroscopic findings we classified tibiotarsal joint impingement syndromes into three types, namely: 1) bone impingement; 2) fibrous impingement where both site and grade are considered; 3) impingement synovialis subtalaris.

CONCLUSIONS

MRI appears to be a fundamental diagnostic imaging tool in depicting and detailing the various patterns and sites of the impingement syndrome of the tibiotarsal joint thus allowing an objective classification.

Knee impingement syndromes

INTRODUCTION

The so-called knee impingement syndromes are very frequently reported in both professional and amateur sportsmen.

PURPOSE

The objective of our study was to classify the most frequent knee changes responsible for such syndromes considering both pathology and diagnostic work-up.

MATERIAL AND METHODS

Our patients complained of aspecific symptoms related to articular meniscal, ligament or cartilage, conditions. The site of pain was periarticular and there was no apparent sign of acute traumatic events. All individuals, aged 16-55, practised sports at different levels and women were the majority of the sample. The study was carried out from 1995 to 1997 and all the medical records presented in occasion of the sports-medicine check-up were reviewed.

RESULTS

The sites of symptom onset were divided into medial, lateral, anterior and posterior. For each of them the most frequent conditions which could be defined as impingement syndromes, were defined paying particular attention to the possible methods of diagnosis useful to classify the disorder. As for anterior syndromes, patellofemoral disorders were the most frequent findings. They were associated with either incorrect torsion movements of the lower limbs or local dysplasia. Alterations in the single skeletal and cartilage structures were reported. Always referring to anterior syndromes, Hoffa's fat pad imflammation and the jumper's knee were a less frequent finding. As for posterior impingement syndromes, the most frequent abnormalities involved the insertional tract of the midcalf muscle associated with bursa reaction and insertional popliteus hypertrophy. As for medial syndromes, the most frequent abnormality involved the parapatellar synovial fold whose symptoms can be often mistaken for a meniscal injury. Less frequent is the involvement of the 'pes anserinus' tendinitis and the insertional enthesopathy of the semimembranosus muscle. As for lateral syndromes, the phlogistic involvement of the distal insertional tract of the broad fascia tensor tendon with bursa reaction is very frequently reported, while the inflammation of the popliteal tendon and of the femoral bicipital tendon is less common.

CONCLUSIONS

Although less frequent than meniscal and ligament injuries, impingement syndromes must be taken into due consideration when looking for knee disorders resorting to different diagnosis methods. Diagnostic imaging is very useful in this regard as it allows a proper and correct diagnosis procedure for any single condition.

Superficial peroneal nerve entrapment in a young athlete: the diagnostic contribution of magnetic resonance imaging

Fascial entrapment of the superficial peroneal nerve produced severe pain in the ankle and foot of a 16-year-old female athlete after several sprains of the same ankle. The pain coexisted with erythema and sensory alteration of the area involved. Magnetic resonance imaging confirmed the diagnosis of this unusual neuropathy. Limited fasciectomy, at the point where the nerve becomes subcutaneous, relieved all symptoms.

[Magnetic resonance arthrography. Preliminary experience in study technic and main diagnostic applications]

In the study of osteoarticular conditions, MRI makes a definite diagnostic improvement, even though some problems are still to be solved. Thus, on the basis of their arthrographic experience, the authors experimentally applied this technique to MRI, to assess the actual feasibility of MR arthrography. Forty-three patients were selected to undergo MR examinations after the intraarticular injection of 15-20 ml paramagnetic contrast agent (Gd-DTPA), with 0.25% saline solution. Before MR arthrography every patient underwent a baseline MR arthrography exam. Normal anatomy was better depicted with MR arthrography. In all cases, even small lesions and other structural changes missed at baseline MRI were demonstrated. Therefore, in agreement with previous arthrographic and CT arthrographic reports, we believe MR arthrography to be a simple technique improving MR diagnostic capabilities in selected cases.

[Double-contrast arthrography in recurrent luxations of the shoulder]

One hundred and ninety-three shoulder arthrographies were performed between 1979 and 1985 on patients affected by recurrent dislocations. The diagnostic doubt was cleared up in 162 cases (83%). Arthrographic diagnosis was confirmed by pathological findings in 92% of the patients who underwent surgery. The double-contrast technique under local anaesthesia with anterior access is suggested, since it allows several arthrograms in different projections. Thus, an analytic study of the articular damage can be carried out. The patterns of each projection are briefly shown. Revision of case histories points out that: a) the use of arthrography should always be assessed on a clinical-radiological basis for each patient; b) there is no doubt as to the usefulness of this examination as a direct means of exploration, as far as the articular damage is concerned, not only as an aid to future surgery, but also in the follow-up of the results of the treatment in the long run.

[Goodpasture's syndrome. Two cases (author's transl)]

A brief report of two cases of Goodpasture's pneumonephrotoxic syndrome offers the greatest contribution that can be given by renal radiographic signs obtained by contrast radiography. Their association with already known pulmonary signs helps diagnosis and is an absolute indication for nephrobiopsy.

[Radiology in the diagnosis of Goodpasture's syndrome]

Radiology has an important part to play in Goodpasture's syndrome. The radio-sympatomatological value of lung changes are clarified and subdivided into primary, secondary and mixed, and mention made of the possible significance of cardiomegaly, where present. Special attention is paid to the importance of radiological exploration of the kidneys for the recognition of changes whose concomitance with lung changes may suggest diagnosis of Goodpasture's syndrome.