Radiographic and Clinical Evidence for Osteoarthritis at Medium-Term Follow-up after Arthroscopic Partial Medial Meniscectomy

OBJECTIVE

The purpose of this study is to assess if incident radiographic osteoarthritis (OA) is associated with clinical OA symptoms at midterm follow-up after arthroscopic partial medial meniscectomy (APMM).

DESIGN

A total of 44 patients (43% females, mean age 50.1 ± 2.8 years, minimum 5.6-year follow-up) with isolated medial meniscal tears and no-to-mild preoperative radiographic OA underwent APMM. Incident radiographic OA was assessed using the modified Kellgren-Lawrence (K-L) classification. Patients completed the Knee Injury and Osteoarthritis Outcomes Score (KOOS), and subscale thresholds for assessment of a symptomatic knee (KOOS OA criteria) and for Patient non-Acceptable Symptom State (PASS-N) following anterior cruciate ligament reconstruction (ACL-R) were calculated.

RESULTS

Incident medial compartment OA occurred in 50% of patients. Morbidly obese patients (body mass index ≥35 kg/m²) were more likely to demonstrate incident radiographic OA (100% vs. 41%, P = 0.002). Forty-three percent of patients met KOOS OA criteria, while 77% were PASS-N. Females were more likely to meet KOOS OA criteria (73% vs. 21%, P = 0.009). Patients with incident radiographic OA in any compartment were more likely than those without radiographic OA to meet KOOS OA criteria (71% vs. 17%, P = 0.008). Patients with preoperative K-L grade 2 changes in any compartment were more likely to meet KOOS OA criteria than those without K-L grade 2 changes in any compartment (83% vs. 35%, P = 0.037).

CONCLUSIONS

Roughly half of APMM patients will have incident radiographic OA within 6 years of APMM, and this risk increases with obesity. Females and patients with incident radiographic OA are more likely to meet clinical thresholds for OA.

Three-Column Classification System for Tibial Plateau Fractures: What the Orthopedic Surgeon Wants to Know

Recent orthopedic surgical literature emphasizes a three-column approach to understand and guide the treatment of tibial plateau fractures. This three-column classification system published in 2010 relies on preoperative CT images to depict injuries to the medial, lateral, and posterior columns of the tibial plateau and improves surgical outcomes in complex tibial plateau fractures with coronal fracture planes and posterior plateau fracture fragments requiring dorsal plating. Tibial plateau fracture classification systems traditionally used by radiologists and orthopedic surgeons, including the Schatzker and the Arbeitsgemeinschaft für Osteosynthesefragen-Orthopedic Trauma Association (AO-OTA) classification systems, rely on findings at anteroposterior radiography and lack the terminology to accurately characterize fractures in the coronal plane involving the posterior tibial plateau. Incorporating elements from the contemporary three-column classification system into radiology reports will enhance radiologists' descriptions of these injuries. It is essential for radiologists to understand the role of clinical assessment and the pertinent imaging findings taken into consideration by orthopedic surgeons in their management of these injuries. This understanding includes familiarity with injury patterns and how they relate to mechanism of injury, patient demographics, and underlying pertinent comorbidities. Evaluating findings on initial radiographs is the basis of tibial plateau fracture diagnosis. Additional information provided by preoperative cross-sectional imaging, including two-dimensional and three-dimensional CT and MRI in specific circumstances, aids in the identification of specific soft-tissue injuries and fracture morphologies that influence surgical management. These specific fracture morphologies and soft-tissue injuries should be identified and communicated to orthopedic surgeons for optimal patient management. Online DICOM image stacks are available for this article. ^©RSNA, 2020.

Percutaneous CT-Guided Core Needle Biopsies of Head and Neck Masses: Technique, Histopathologic Yield, and Safety at a Single Academic Institution

BACKGROUND AND PURPOSE

CT-guided head and neck biopsies can be challenging due to the anatomy and adjacent critical structures but can often obviate the need for open biopsy. A few studies and review articles have described approaches to biopsy in the head and neck. This retrospective study evaluated technical considerations, histopathologic yield, and safety in CT-guided head and neck core needle biopsies.

MATERIALS AND METHODS

A retrospective review of head and neck biopsies performed from January 2013 through December 2019 was conducted. Clinical diagnosis and indication, patient demographics, mass location and size, biopsy needle type, technical approach, dose-length product, sedation details, complications, diagnostic histopathologic yield, and the use of iodinated contrast were recorded for each case.

RESULTS

A total of 27 CT-guided head and neck core needle biopsies were performed in 26 patients. The diagnostic sample rate was 100% (27/27). A concordant histopathologic diagnosis was obtained in 93% (25/27) of cases. There was a single complication of core needle biopsy, a small asymptomatic superficial hematoma.

CONCLUSIONS

Percutaneous CT-guided biopsy of deep masses in the head and neck is safe and effective with careful biopsy planning and has a high diagnostic yield that can obviate the need for open biopsy.

Gene Expression in Meniscal Tears at the Time of Arthroscopic Partial Meniscectomy Predicts the Progression of Osteoarthritis Within 6 Years of Surgery

Background:

While knees with meniscal tears are associated with a heightened risk of developing osteoarthritis (OA), it is difficult to predict which patients are at the greatest risk for OA. Gene signatures in menisci that are resected during arthroscopic partial meniscectomy (APM) may provide insight into the risk of OA progression.

Hypothesis:

Meniscal gene signatures at the time of APM will predict radiographic OA progression.

Study Design:

Case series; Level of evidence, 4.

Methods:

Meniscal fragments were collected from 38 patients without OA during clinically indicated APM of the medial meniscus. The expression of 28 candidate genes with known roles in cartilage homeostasis, OA, extracellular matrix degradation, and obesity was assessed by quantitative real-time polymerase chain reaction. Weightbearing radiographs obtained before surgery and at final follow-up were graded by a musculoskeletal radiologist using the Kellgren-Lawrence classification of OA. The association of meniscal gene expression at baseline with the progression of radiographic OA was determined.

Results:

Gene expression and baseline and follow-up radiographic data were available from 31 patients (81.6%) at a mean follow-up of 6.2 ± 1.3 years. Patients without OA progression had significantly higher expression of 7 genes: MMP9 (5.1-fold; P = .002), IL8 (2.9-fold; P = .016), CCL3 (3.7-fold; P = .032), CCL3L1 (4.5-fold; P = .008), CXCL6 (6.2-fold; P = .010), LEP (5.2-fold; P = .004), and RETN (46-fold; P = .008).

Conclusion:

Gene expression in the meniscus at the time of APM may be associated with the risk for progression of OA after surgery. Elevated expression of the aforementioned genes may reflect a chondroprotective response. Stratifying the risk for OA progression after APM could facilitate targeted interventions to delay or prevent the development of OA. Further studies in a larger cohort with an extended follow-up, and inclusion of additional genes, are warranted to better characterize this association.

Musculoskeletal Radiology Fellowship Application and Selection Process: Perceptions of Residents, Fellows, and Fellowship Directors

RATIONAL AND OBJECTIVES

This study aimed to assess resident, fellow, and fellowship director perceptions of the musculoskeletal (MSK) radiology fellowship application process.

MATERIALS AND METHODS

A task group constructed three surveys with questions about current and "ideal" fellowship application and selection processes. Surveys were distributed to MSK fellowship directors, who were also asked to give separate surveys to current fellows. US and Canadian radiology residency directors were asked to distribute surveys to current R3 and R4 residents. Responses were tabulated and analyzed.

RESULTS

Responses were received from 47 MSK fellowship directors, 73 MSK fellows, and 147 residents. Fellowship directors and fellows reported that most fellowship offers occur between July and September of the R3 year, although 19% of directors made offers as early as the R2 year. Of the 43 director respondents, 31 (72%) noted "pressure from other programs" as the main driving force behind their policies, but 28 (65%) felt that their timelines were "too early." A formal match was supported by 55% of responding fellowship directors, 57% of fellows, and 61.9% of residents, citing "fairness" as a major justification.

CONCLUSIONS

MSK radiology fellowship selection occurs as early as the R2 year, before many residents have had substantial exposure to different subspecialties. An "arms race" has developed with programs moving their timelines earlier in response to the actions of other programs, presumably to avoid missing the best candidates. Although a majority of respondents would support a formalized match to increase fairness, there is not universal agreement that it would be the best approach.

Impact of Shoulder Sonography on Clinical Decision Making

OBJECTIVES

To assess the impact of musculoskeletal shoulder sonography (US) on clinical decision making.

METHODS

This Health Insurance Portability and Accountability Act-compliant retrospective study received Institutional Review Board approval with a waiver of informed consent. Consecutive musculoskeletal shoulder US examinations ordered over a 12-month period were retrospectively reviewed. The medical records of each patient were analyzed, recording immediate pre- and post-US treatment plans. Treatment plans were categorized as follows: 1, no further treatment; 2, conservative management/physical therapy; 3, therapeutic injection; 4, surgical intervention; 5, change in diagnosis; and 6, need additional imaging. Data were analyzed by nonparametric statistical methods.

RESULTS

A total of 935 patient examinations met inclusion criteria. Of 935 patients, 591 (63.2%) had a post-US treatment plan that differed from pre-US treatment, showing a statistically significant impact on patient treatment (P < .001). In 744 of the 935 examinations (79.6%), the treating physician initially prescribed conservative therapy as a treatment plan; 423 of those 744 patients (56.9%) were subsequently prescribed a more invasive form of treatment. Of the remaining 191 of 935 patients (20.4%) initially treated with invasive treatment, 101 (52.9%) received a change in the treatment plan after the US examinations, with 46 patients (24.1%) relegated to noninvasive treatment. Sonography also played a role in surgical planning, with 25 studies (2.7%) specifically performed to evaluate rotator cuff integrity when deciding between conventional and reverse shoulder arthroplasty.

CONCLUSIONS

Musculoskeletal shoulder US has a substantial impact on clinical decision making and patient treatment.

Percutaneous Spinal Ablation in a Sheep Model: Protective Capacity of an Intact Cortex, Correlation of Ablation Parameters with Ablation Zone Size, and Correlation of Postablation MRI and Pathologic Findings

BACKGROUND AND PURPOSE

Despite the growing use of percutaneous ablation therapy for the treatment of metastatic spine disease, several issues have yet to be fully addressed. Our aims were to determine whether the vertebral body cortex protects against ablation-induced spinal cord injury; correlate radiofrequency, cryo-, and microwave ablation parameters with resulting spinal ablation zone dimensions and describe normal spinal marrow postablation changes on MR imaging.

MATERIALS AND METHODS

Ten thoracolumbar vertebrae in 3 sheep were treated with radiofrequency ablation, cryoablation, or microwave ablation under fluoroscopic guidance. Technique parameters were chosen to produce ablation zones that exceeded the volume of the vertebral bodies in sheep 1 and were confined to the vertebrae in sheep 2 and 3. Expected ablation zone dimensions were based on data provided by the device manufacturers. Postablation MR imaging was performed at 48 hours (sheep 1) or 7 days (sheep 2 and 3).

RESULTS

In sheep 1, cryoablation and microwave ablations extended into the spinal canal and caused histologically confirmed neurologic injury, but radiofrequency ablation did not. The mean difference between the lengths of the radiofrequency ablation zone dimensions measured on gross pathology compared with those expected was 9.6 ± 4.1 mm. The gross pathologic cryo- and microwave ablation zone dimensions were within 1 mm of those expected. All modalities produced a nonenhancing ablation zone with a rim of enhancement, corresponding histologically to marrow necrosis and hemorrhagic congestion.

CONCLUSIONS

An intact cortex appears to protect against radiofrequency ablation-induced spinal cord injury, but not against non-impedance-based modalities. Ablation dimensions produced by microwave and cryoablation are similar to those expected, while radiofrequency ablation dimensions are smaller. Ablation of normal marrow produces a rim of enhancement at the margin of the ablation zone on MR imaging.

Osteolipoma of the knee

A case of a right knee intra-articular osteolipoma in a 64-year-old man is reported. The patient presented for evaluation of a 1-year history of nontraumatic, mechanically-exacerbated, medial-sided right knee pain. Radiographs demonstrated a partially calcified 3.0 cm mass anterior to the distal medial femur at the suprapatellar fossa. Magnetic resonance imaging examination confirmed a 4.0 × 3.6 cm well-circumscribed mass deep to the medial patellofemoral ligament, with predominantly fat characteristics on T1-weighted and T2-weighted sequences. The mass had irregular ossification superiorly with surrounding heterogeneous enhancement. Histologic examination of an excisional biopsy showed the lesion to be an osteolipoma. Osteolipoma is a rare histologic variant of lipoma with osseous metaplasia, but should be considered in the differential of a fat-containing neoplasm with ossification.

Eosinophilic granuloma of the sacrum treated with radiation therapy: a case report

BACKGROUND CONTEXT

Eosinophilic granulomas (EGs) of the sacrum have been reported in fewer than 10 patients. Treatment algorithms for these tumors remain poorly defined; there are no reports of treating solitary sacral EG with radiation therapy (RT).

PURPOSE

This study aimed to describe the presentation, treatment, and outcome of sacral EG in an adult patient with intractable pain and radiculopathy, treated in a novel fashion with RT.

STUDY DESIGN/SETTING

The study design was a case report from a tertiary cancer referral center.

METHODS

Patient records, imaging, and pathology were reviewed.

RESULTS

A 35-year-old man received 20 Gy of radiation to his S1 EG lesion. He subsequently developed vertebra plana of S1 causing symptomatic L5-S1 stenosis, but 15 months after RT treatment was free of pain or tumor recurrence.

CONCLUSION

Radiation therapy is an effective treatment option for sacral EG causing severe axial pain and neural impingement.

Combined Ablation and Radiation Therapy of Spinal Metastases: A Novel Multimodality Treatment Approach

BACKGROUND

Radiation therapy (RT) is the current gold standard for palliation of painful vertebral metastases. However, other percutaneous modalities such as radiofrequency ablation (RFA), cryoablation, and vertebral augmentation have also been shown to be effective in alleviating symptoms. Combined RT and ablation may be more effective than either therapy alone in palliating painful metastatic disease to the spine.

OBJECTIVE

To evaluate the safety and efficacy of combined ablation, either RFA or cryoablation, and RT in the treatment of spinal metastases.

STUDY DESIGN

Retrospective study.

SETTING

This is a retrospective study at a single institution.

METHODS

Medical records of all patients who underwent ablation of spine lesions at a single institution between March 2012 and June 2014 were reviewed; patients treated with both RT and either RFA or cryoablation concurrently were identified. Pain scores before and after RFA were measured with the numerical rating scale (NRS) (0-10 point scale) and compared. Procedural complications, changes in general activity level, and pain medication usage after ablation were also recorded. When available, follow-up imaging was evaluated for evidence of residual or recurrent disease.

RESULTS

Twenty-one patients with 36 spine metastases were treated with RT and percutaneous ablation concurrently; either RFA (21/22) or cryoablation (1/22). One patient received 2 separate RFA treatments. Overall, mean worst pain score (8.0, SD = 2.3) significantly decreased at both one week (4.3, SD = 3.1; P < .02) and 4 weeks (2.9, SD = 3.3; P < .0003). Temporary post-procedural radicular pain occurred after one RFA treatment (4.5%; 1/22). Seven patients had radiation resistant tumors (renal cell, melanoma, or sarcoma). Post-procedural imaging (median 6 months; range 2-27 months) showed stable treated disease in 12/13 treatments at 3 months and 10/10 at 6 months.

LIMITATIONS

The therapeutic effect of vertebral augmentation versus percutaneous ablation cannot be separated in this retrospective study. Radiation treatment protocols were variable and included both stereotactic body and conventional RT which may have different safety and efficacy profiles.

CONCLUSION

Percutaneous ablation and concurrent RT is safe and effective in palliating painful spinal metastases and can be effective in those who have radiation resistant tumor histology.

Percutaneous discal cyst rupture in a professional football player using sublaminar epidural injection for thecal sac displacement

A case of percutaneous discal cyst rupture in a 25-year-old professional American football player is reported. The patient presented with a 3-day history of severe left-sided back pain. Magnetic resonance imaging examination demonstrated a discal cyst effacing the left L4-L5 lateral recess, with interposed thecal sac. A sublaminar epidural injection was performed displacing the thecal sac, exposing the discal cyst, and allowing for percutaneous perforation. The patient had complete resolution of symptoms after discal cyst rupture and was able to compete in a professional football game 3 days later. Computed tomography-guided percutaneous rupture is a therapeutic modality that may be considered for treatment of a symptomatic discal cyst.

Traumatic Tear of the Latissimus Dorsi Myotendinous Junction: Case Report of a CrossFit-Related Injury

A case of a latissimus dorsi myotendinous junction strain in an avid CrossFit athlete is presented. The patient developed acute onset right axillary burning and swelling and subsequent palpable pop with weakness while performing a “muscle up.” Magnetic resonance imaging examination demonstrated a high-grade tear of the right latissimus dorsi myotendinous junction approximately 9 cm proximal to its intact humeral insertion. There were no other injuries to the adjacent shoulder girdle structures. Isolated strain of the latissimus dorsi myotendinous junction is a very rare injury with a scarcity of information available regarding its imaging appearance and preferred treatment. This patient was treated conservatively and was able to resume active CrossFit training within 3 months. At 6 months postinjury, he had only a mild residual functional deficit compared with his preinjury level.

Imaging evaluation of treated benign bone tumours

A number of benign bone tumours can be treated with curettage and packing with either bone cement or graft. It is essential that the radiologist be familiar with both the normal and abnormal post-operative imaging appearance of these treated tumours. Through the use of numerous imaging examples, we aim to provide a pictorial review of the expected post-operative appearance of benign bone tumours treated with curettage and packing, as well as the imaging features of recurrence, the most common potential complication.

Treatment of metastatic spinal lesions with a navigational bipolar radiofrequency ablation device: a multicenter retrospective study

BACKGROUND

Spinal metastatic lesions are a common occurrence among oncology patients and contribute to significant morbidity. Treatment options have been limited in their effectiveness and scope to this point.

OBJECTIVE

This study aims to report the safety and efficacy of radiofrequency ablation (RFA) of malignant spinal lesions using a novel RFA bipolar tumor ablation system which includes a navigational electrode containing 2 active thermocouples.

STUDY DESIGN

IRB approved multicenter retrospective review of patients receiving RFA as a treatment of metastatic osseous lesions between March 2012 and March 2013.

SETTING

This study consists of patients from 5 large academic centers.

METHOD

One hundred twenty-eight metastatic lesions were identified in 92 patients who underwent a total of 96 procedures. Cement augmentation was performed when the vertebral body was at risk or had a pathological fracture. Visual analogue scale (VAS) scores were obtained preoperatively as well as postoperatively at the one week, one month, and 6 month time points. Interval change in the patients' pain medications was recorded. Postoperative imaging was used to assess tumor burden at the treated level when available.

RESULTS

RFA was technically successful in all of the lesions without complication or thermal injury. Our study demonstrated significant (P < 0.01) decreases in the VAS scores at one week, one month, and 6 months postoperatively. In our largest center, 54% of our patients experienced a decrease and 30% had no change in their pain medications postoperatively. Sixty-two percent of the spinal lesions in this largest institution were located in the posterior vertebral body. Post-ablation imaging confirmed size of ablation zones consistent with that measured by the thermocouples.

LIMITATIONS

The main limitations of this study are the heterogeneous patient population, data set, and potential confounding variable of concurrent cement augmentation.

CONCLUSION

The STAR System is an RFA device that was safely and effectively used in the treatment of spine metastatic osseous lesions. This new device allows RFA treatment of previously untreatable lesions with resultant reduction in pain that was not controlled by systemic or radiation therapy.

Intra-articular synovial sarcoma

A case of right knee intra-articular synovial sarcoma in a 26-year-old man is reported. The patient had experienced 12 to 18 months of chronic posterior right knee pain with flexion contracture of the leg. Magnetic resonance imaging (MRI) examination demonstrated nonspecific characteristics of a well-circumscribed, homogeneous mass within the posterior lateral compartment of the knee joint. The mass was isointense and hyperintense to muscle on T1- and T2-weighted sequences respectively, and initially clinically diagnosed as a localized tenosynovial giant cell tumor. However, histological examination showed the lesion to be a synovial sarcoma arising from the synovium of the knee joint. Synovial sarcoma may have a nonspecific MR appearance, especially when less than 5 cm in size, often simulating a less aggressive process. Primary intra-articular origin may predispose to earlier presentation, and therefore, radiological evaluation of smaller masses. Nonspecific MR characteristics of small, intra-articular masses provide a diagnostic dilemma. Synovial sarcoma should be considered in the differential diagnosis when distinguishing MR characteristics of other common joint-centered entities are not present.

[Poorly-differentiated thyroid carcinoma: morphological verification and differential diagnosis]

Poorly-differentiated thyroid carcinoma is a stage in the development of anaplastic carcinoma from well-differentiated neoplastic transformation of follicular epithelium. Such tumors differ with respect to histological pattern and age. For instance, patients, aged 50 and more, revealed great nodular size (50-70 mm), marked invasion, large cells with high mitotic index and solid and/or insular pattern. In the group under 40, incapsulated poorly-differentiated tumors were more frequent; they had trabecular histological pattern alone with a much smaller size (ca. 30mm). Further clinico-morphological studies might solve the problem of the connection between cyto- and histological pattern, on the one hand, and clinical course and prognosis, on the other.