The musculoskeletal manifestations of haemophilia: a review of the imaging findings

Haemophilia is a common hereditary cause of bleeding diathesis and the musculoskeletal system is frequently affected. Repeated episodes of haemarthrosis initiate a cascade towards haemophilic arthropathy, a disabling and deforming joint disease with both degenerative and inflammatory features, which include articular cartilage loss, bone erosions, and synovitis. Haemophilic pseudotumour and intra-muscular haematoma make up the remainder of the musculoskeletal manifestations of this systemic condition. Radiological assessment is vital in the assessment and follow-up of these haemophilic complications and MRI is the reference standard. This article summarises the radiological findings relevant to the diagnosis and monitoring of this complex patient group.

Estimated cumulative X-ray exposure and additional cancer risk during the evaluation and treatment of scoliosis in children and young people requiring surgery

INTRODUCTION

Clinicians and patients must weigh the benefits of radiological imaging against the risks of radiation exposure in the diagnosis and treatment of scoliosis. This report aims to estimate the cumulative absorbed and equivalent dose of radiation in patients undergoing surgical treatment for scoliosis, and to present this as an estimated risk of cancer compared to background radiation levels.

METHODS

Retrospective review of estimated absorbed dose on the Computerised Radiology Information System (CRIS^®). Patients undergoing surgical correction of scoliosis (age ≤ 25) from August 2010 to August 2015 investigated. Estimated absorbed dose [milligrays (mGy)] recorded. Pedicle screws inserted using image intensification. Equivalent dose [millisieverts (mSv)] and additional cancer risk calculated from the National Research Council document 'Health risks from exposure to low levels of ionising radiation' (2006).

RESULTS

271 patients identified. Mean age 15 (range 2-25). Mean total absorbed dose 2136 mGy [standard deviation (SD) 1700 mGy]. Mean number of plain spine radiographs was 8 (SD 3) with total 1884 mGy exposure (SD 1609 mGy). Additional dose provided by CT (mean 0.17 episodes), plain chest and abdominal radiographs and image intensification. Mean number of image intensification episodes was 1.1 with mean estimated exposure 180 mGy (SD 238 mGy). Image intensification accounted for 8% of the estimated absorbed dose during treatment. Estimated mean effective dose delivered was 20.952 mSv equating to an additional cancer risk of 0.27-0.45%.

CONCLUSION

Additional cancer risk from cumulative imaging is small and equivalent to approximately 8 years of natural background radiation. Use of image intensification for pedicle screw insertion is a minor contribution (8%) to the total patient dose.

Do ultrasound guided trochanteric bursa injections of corticosteroid for greater trochanteric pain syndrome provide sustained benefit and are imaging features associated with treatment response?

AIM

To assess intra-bursal corticosteroid injections (ICSI) efficacy and duration of action in the management of greater trochanteric pain syndrome (GTPS). The secondary aim was to identify patient and ultrasound (US) features predictive of treatment response.

MATERIALS AND METHODS

Consecutive prospectively recruited patients undergoing US-guided ICSI therapy for GTPS received baseline pre-injection questionnaires assessing pain at rest and activity, demographics and comorbidities. Baseline US and radiography findings were reported prospectively. Follow-up was performed at 6 weeks and 6 and 12 months, and change in pain scores assessed using the Wilcoxon signed rank test. Logistic regression examined associations between demographics, US findings, and a clinically significant reduction in pain score (≥50%).

RESULTS

Over 6 months, 127 patients were recruited with a median age of 63.5 years and 90% were female. The greatest pain reduction was between baseline and 6 weeks at activity (median 8 versus 5, p<0.001). The majority of patients noted a reduction in pain score, but the percentage of patients receiving a ≥50% reduction at 6 weeks, 6 months, and 12 months for pain at rest was 41%, 37%, and 36%, respectively. Regression models suggested only gluteus medius bursitis was weakly associated with pain reduction.

CONCLUSION

ICSIs confer a benefit in pain reduction to a large proportion of patients in the short term, but this may not be reduced by a clinically significant amount. This small effect size and lack of predictive imaging features suggests initial management including subsequent steroid injection could be provided without imaging guidance in the majority of cases.

Do quantitative and qualitative shear wave elastography have a role in evaluating musculoskeletal soft tissue masses?

Objectives

To determine if quantitative and qualitative shear wave elastography have roles in evaluating musculoskeletal masses.

Methods

105 consecutive patients, prospectively referred for biopsy within a specialist sarcoma centre, underwent B-mode, quantitative (m/s) and qualitative (colour map) shear wave elastography. Reference was histology from subsequent biopsy or excision where possible. Statistical modelling was performed to test elastography data and/or B-mode imaging in predicting malignancy.

Results

Of 105 masses, 39 were malignant and 6 had no histology but benign characteristics at 12 months. Radiologist agreement for B-mode and elastography was moderate to excellent Kw 0.52-0.64; PABAKw 0.85-0.90). B-Mode imaging had 78.8% specificity, 76.9% sensitivity for malignancy. Quantitatively, adjusting for age, B-mode and lesion volume there was no statistically significant association between longitudinal velocity and malignancy (OR [95% CI] 0.40[0.10, 1.60], p=0.193), but some evidence that higher transverse velocity was associated with decreased odds of malignancy (0.28[0.06, 1.28], p=0.101). Qualitatively malignant masses tended to be towards the blue spectrum (lower velocities); 39.5% (17/43) of predominantly blue masses were malignant, compared to 14.3% (1/7) of red lesions.

Conclusions

Quantitatively and qualitatively there is no statistically significant association between shear wave velocity and malignancy. There is no clear additional role to B-mode imaging currently.

Key Points

• Correlation between shear wave velocity and soft tissue malignancy was statistically insignificant

• B-mode ultrasound is 76.9 % sensitive and 78.8 % specific

• Statistical models show elastography does not significantly add to lesion assessment