Abstracts Programme 2003

Transcription

European Society of
Musculoskeletal Radiology
10th Annual Meeting
Aarhus, Denmark
Friday and Saturday
June 13-14th, 2003
Abstract Book
Educational course:
Inflammatory joint disorders
Scientific sessions:
All aspects of musculoskeletal radiology
Page
Educational lectures
Scandia Ballroom, Friday 13th June
Abstract
number
Time
Imaging of joints and inflammation - Educational Course I
1
08.30-08.50 General differentiation of radiographic features – an overview
2
08.50-09.20 MRI of peripheral joint arthritis with emphasis on subchondral bone
and cartilage
3
09.20-09.40 Assessment of vascularity, perfusion and angiogenesis with
radiological methods - application on joint inflammation
4
09.40-10.10 Osteoporosis in inflammatory disorders
5
6
7
10.50-11.10 Therapeutic and diagnostic ultrasonography
11.10-11.30 Nuclear Medicine in the assessment of inflammatory disorders
11.30-11.50 Differentiation at imaging between rheumatoid and seronegative
arthritis
8
9
10
11
12
01.00-01.20
01.20-01.40
01.40-02.00
02.00-02.20
02.20-02.40
13
14
15
16
Rheumatoid arthritis (RA) - Educational Course II
Clinical aspects
Imaging of the upper extremity
Imaging of the lower limb
Rheumatoid arthritis - Arthritis of cervical spine
MRI of peripheral RA with emphasis on assessment of inflammation
Seronegative spondyloarthropathy (SpA) - Educational Course III
03.10-03.30 Clinical aspects
03.30-03.50 Imaging of the sacroiliac joints: normal anatomy and the different SpA
forms
03.50-04.10 The spine: imaging of the different forms of SpA
04.10-04.30 Pustulotic arthro-osteitis/SAPHO syndrome
8
Main Author
A. Cotten
C.G. Peterfy/
H. Genant
M. Reiser
H. Genant
E. McNally
J. Theill
W.C.G. Peh
17
K.S. Pedersen
J. Beltran
P. O’Connor
I. McCall
M. Oestergaard
30
B. S. Christensen
N. Egund
V. Jevtic
A.G. Jurik
Scandia Ballroom, Saturday 14th June
19
Childhood disorders - Educational Course IV
08.00-08.20 Clinical aspects
08.20-08.50 Imaging of juvenile idiopathic arthritis, systemic, peripheral and axial
arthritis
08.50-09.10 Haemophilia, plain radiography and MRI
20
21
Crystal induced and related disorders - Educational Course V
09.20-09.40 Gout and hydroxyappatite arthritis
09.40-10.00 Pseudogout and related disorders
22
23
24
Inflammatory disorders in sports medicine - Educational Course
VI
10.40-11.00 Posttraumatic synovitis
11.00-11.20 Tendinitis
11.20-11.50 Enthesopathy
17
18
25
26
27
28
29
01.00-01.20
01.20-01.40
01.40-02.00
02.00-02.20
02.20-02.40
Conditions simulating rheumatological disorders - Educational
Course VII
Synovitis in non-rheumatological disorders
Tumours and tumour-like conditions
Infections of the axial skeleton
Septic arthritis
Neuropathic arthropathy
2
40
T. Herlin
K. Johnson
H. Pettersson
43
M. Cobby
M. Zanetti
46
F. Kainberger
C. Faletti
O´Connor
49
H. Imhof
A.M. Davies
V. Cassar-Pullicino
K. Bohndorf
A. Chevrot
Scientific presentations
Nortvegia Hall, Friday 13th June
Scientific session 1a,
Knee joint, 8.30-10.00 am.
30
31
32
33
34
35
36
37
54
08.30-08.50 Cystic lesions around the knee – Keynote lecture
08.50-09.00 The popliteal hiatus: a spread path for intra-articular processes of the
knee joint
09.00-09.10 Unexpected MR Imaging findings in patients with the clinical
diagnosis of knee osteoarthritis and minor or no plain x-ray findings
09.10-09.20 MRI assessment of knee osteoarthritis: Inter-observer and intraobserver reproducibility of a compartment-based scoring system
09.20-09.30 MRI of the knee after unreamed intramedullary nailing of tibia
09.30-09.40 Radiology of the knee in diastropheic dysplasia. A pre- and post
operative study
09.40-09.50 Quantification of knee joint angulation with axis measurement of the
lower extremity on conventional and digital radiographs
09.50-10.00 Painful bipartite patella: MRI characteristics
F.M. Vanhoenacker
A.I. Garcia
T. Nakopoulou
P.R. Kornaat
J. Gustafsson
M. Lohmann
J. Sailer
F.M. Vanhoenacker
Scientific session 2,
Hip joint and feet, 10.30-12.00 am.
38
39
40
41
42
43
44
45
10.30-10.50 Radiological evaluation of the dysplastic hip in patients undergoing
Gantz osteotomy – Keynote lecture
10.50-11.00 Multiclice CT in evaluation of total hip arthroplasty
11.00-11.10 Hip joint space area in standing and supine radiographs
11.10-11.20 Effectiveness of intraarticular steoid injection in osteoarthritis of the
hip
11.20-11.30 Transient osteoporosis of the hip: MR imaging patterns and perfusion
characteristics on contrast-enhanced dynamic imaging
11.30-11.40 Distal fat pad displacement in diabetics with neuropathic foot
deformity: MR evaluation
11.40-11.50 Diabetic foot complications, role of medical imaging in the
differential diagnosis of osteomyelitis, Charcot arthropaty and
cellulitis in diabetic foot pathology: a prospective study in 53 patients
11.50-12.00 Withdrawn
63
K. Tallroth
M. Maas
L. Niemitukia
P. Robinson
A.H. Karantanas
S.A. Bus
P. Van Dyck
Intervention, 1.00-2.30 pm.
46
47
48
49
50
51
52
53
73
01.00-01.20 Modern techniques in CT guided interventions of the musculoskeletal
system – Keynote lecture
01.20-01.30 Vertebroplasty (VP) guided by CT fluoroscopy – our experience Oct.
99-April 2003
01.30-01.40 Mid-term clinical results after percutaneous vertebroplasty
01.40-01.50 Treatment of juxta-articular cysts with a biological product
01.50-02.00 Is there a need for antimicrobial prophylaxis in provocation
discography
02.00-02.10 RF ablation of osteoid osteomas of the spine, results in 12 patients
02.10-02.20 Ultrasonographic follow up evaluation of achilles tendinitis treated
with ultrasound guided steroid injections into a retrocalcaneal bursa
02.20-02.30 Biopsy of musculoskeletal lesions: the importance of compartmental
anatomy
W.R. Obermann
E. Perez
R.T. Hoffmann
F. Aparisi
S. Chaudhary
W.R. Obermann
Z. Czyrny
C.F. van Dijke
Spine, 3.00-4.40 pm.
54
55
56
79
03.00-03.20 Imaging of the vertebral apophyseal facet joints: Different SNSA
forms, morphology and differential diagnosis of inflammatory versus
degenerative – Keynote lecture
03.20-03.30 Arw abnormal MRI disc findings in 13-year old children associated
with low back pain? An Epidemiologic study
03.30-03.40 MRI findings in Scheuermann Disease
3
A. Mester
P. Kjær
E. Llopis
57
58
59
60
61
62
03.40-03.50 Unfrequently encountered causes of low back pain other than
herniating disc: CT findings
03.50-04.00 Imaging of the lumbar spine in sciatica: MRI reveal more nondegenerative lesions
04.00-04.10 MR myelography as an adjunt to the MR examination of the spine
04.10-04.20 Reproducibility in quantitative measurements of degenerate disc
changes – comparison to a visual evaluation
04.20-04.30 Congenital scoliosis: MRI and multislice CT evaluation
04.30-04.40 Coccydynia: the utility of magnetic resonance imaging in its
management
D. Passomenos
J. S. Sørensen
P. Ferrer
T.S. Jensen
E. Llopis
T.R. Palser
Room 12, Friday 13th June
Scientific session 1b,
Sports Medicine, 8.30-10.00 am.
63
64
65
70
71
08.30-08.40 Skeletal variants associated with clinical symptoms
08.40-08.50 Sidestrain: a tear of internal oblique musculature
08.50-09.00 Comparison of ultrasound and MR imaging in the assessment of
acute and healing hamstring injuries
09.00-09.10 Thigh splints in a skeletally immaature boy (case report)
09.10-09.20 The reproducibility of tendon ultrasound measurements in healthy
male volunteers
09.20-09.30 Jumper’s knee: dynamical US evaluation during weight bearing
09.30-09.40 Ultrasound-guided sclerosing of neovessels in tendinosis. A new
treatment in painful chronic Achilles tendinosis and jumpers knee
09.40-09.50 Injuries in soccer: the Dutch national team
09.50-10.00 Preliminary results in virtual CT arthroscopy of knee and shoulder
A
B
C
D
E
F
10.30-10.50
10.50-11.10
11.10-11.30
11.30-11.50
11.50-12.10
12.10-12.30
66
67
68
69
86
J. Brtkova
D.A. Connell
D.A. Connell
S. Van de Perre
A.J. Grainger
E. Silvestri
L. Ohberg
M. Maas
M. Falchi
136
Bone densitometry Workshop, 10.30-12.00 am
Epidemiology, diagnosis and treatment
Radiographical features of osteroporosis
The relevance and diagnosis of vertebral fractures
Dual Energy X-ray Absorptiometry
Quantitative Computed Tomography
Vertebroplasty in osteoporosis
J.E. Adams
W.C.G. Peh
H.K. Genant
S. Grampp
G. Guglielmi
D. Wilson
Osteoporosis/MRI/Cartilage, 1.00-2.30 pm.
72
73
74
75
76
77
01.30-01.40 Diagnostic impact of MRI in differential diagnosis of vertebral
osteoporosis
01.40-01.50 Quantitative magnetic resonance imaging of the calcaneus in the
prediction of osteoporotic spine fractures: preliminary results at 3
Tesla
01.50-02.00 Projection reconstruction MR imaging of trabecular bone architecture
02.00-02.10 Signal intensities on T1-WI and fat suppressed T1-WI. What you see
is not what you get
02.10-02.20 Validation and optimization of a multi-echo sequence for T2quantitation of articular cartilage
02.20-02.30 Quantitative 3D MR evaluation of autologous chondrocyte
implantation (ACI) in the knee
92
S. Forgacs
G. Guglielmi
R. Toffanin
J. Gielen
C. Glaser
C. Glaser
Soft tissue tumours, 3.00-4.50 pm.
78
79
80
03.00-03.10 Imaging appearances of acromioclavicular joint cyst, clinically
presenting as tumours of the shoulder region
03.10-03.20 Grading and characterization of soft tissue tumors on magnetic
resonance imaging. A prospective study in 488 patients
03.20-03.30 The study of soft tissue masses using contrast medium in ultrasound:
preliminary experience with a new contrast medium and dedicated
machine
4
96
D.W. Tshering
Vogel
J. Gielen
A. De Marchi
81
82
83
84
85
86
87
88
03.30-03.40 Merkel cell carcinoma, a rare aggressive cutaneous neuroendocrine
tumor: review of MR and imaging findings in thirteen patients and
literature review
03.40-03.50 Imaging spectrum of lipomatous tumours
03.50-04.00 Intramuscular liposarcoma in the forearm: a rare case report
04.00-04.10 Ancient schwannoma of the sensory branch of the median nerve (case
report
04.10-04.20 Solitary cutaneous ancient schwannoman of the elbow (case report)
04.20-04.30 Vascular malformation in the infrapatellar (Hoffa’s) fat pad (case
report)
04.30-04.40 Water-lily sign on MR imaging of primary intramuscular hydatidosis
of sartorius muscle (case report)
04.40-04.50 MR imaging of chronic expanding hematoma
S. Anderson
T. Muthukumar
A. Aurangabadkar
R.B. Comert
R.B. Comert
R.B. Comert
R.B. Comert
J.C. Vilanova
Nortvegia Hall, Saturday 14th June
Spine and bone marrow, 8.30-10.00 am.
89
90
91
92
93
94
95
96
97
08.30-08.40 Comparison of clinical and radiological findings of 89 operated
patients with TBC and pyogenic spondylitis in Latvia
08.40-08.50 MRI of cervical spine metastases – a review of the findings in 30
patients
08.50-09.00 Diagnostic accuracy of a DW-SSFP sequence for differentiating
benign and neoplastic fractures
09.00-09.10 Diffusion weighted imaging (DWI) of bone marrow lesions
09.10-09.20 Feasibility of diffusion weighted imaging in pediatric musculoskeletal
diseases
09.20-09.30 Whole-body MRI for detection skeletal metastases in cancer patients
and in benign pathology of bones
09.30-09.40 Primary lymphoma of bone: imaging findings and contribution of
MRI to the diagnosis
09.40-09.50 Detection of osseous metastases using multi-slice-CT
09.50-10.00 Pathological-Radiological correlations in osteonecrosis (ON) and
bone marrow oedema syndrome (BMES)
103
S. Dzelzite
J. Teh
A. Baur
A. Baur
S.F. Carbone
J.C. Vilanova
A. I. Garcia
A. Wieser
K. Karlinger
Arthritis, 10.30-12.00 am.
98
99
100
101
102
103
104
105
109
10.30-10.50 Extraaxial manifestations of PAO (SAPHO) – a challenge for the
musculoskeletal radiologist – Keynote lecture
10.50-11.00 The sesamoid index in psoriatic arthropathy
11.00-11.10 MRI as a diagnostic tool to evaluate abacterial sacroiliitis in patients
with lower back pain
11.10-11.20 Diagnostic criteria for temporomandibular joint (TMJ) involvement
in patients with juvenile idiopathic arthritis (JIA)
11.20-11.30 Painful cervical calcinosis in a scleroderma patient (case report)
11.30-11.40 Adhesive capsulitis of the shoulder: Sonographic appearance
11.40-11.50 Polymyalgia rheumatica: complex imaging
11.50-12.00 Dedicated extremity 0.2 T MRI of the finger joints: distribution of
synovitis in patients with arthritis
J. Freyschmidt
R. Whitehouse
Ph. Remplik
J. Gelineck
S. Van de Perre
C. Sykes
P.N. Kaposi
A. Savnik
Arthritis, 1.00-2.50 pm.
106
107
108
115
01.00-01.05 Development of a system for computer aided diagnosis (CAD) in
rheumatoid arthritis (1): automated joint lokalization in hand
radiographs
rheumatoid arthritis (2): automated estimation of the bony contour of
metacarpal bones
rheumatoid arthritis (3): automated delineation of defects og the bony
contour of metacarpal boneds
5
P. Peloschek
G. Langs
P. Peloschek
109
110
111
112
113
114
115
116
01.20-01.30 Course of radiographic damage over 10 years in a cohort with early
rheumatoid arthritis
01.30-01.45 MRI of the non-dominant wrist and MCP-joints predicts radiographic
progression in both wrists, metacarpophalangeal and proximal
interphalangeal joints (total sharp score) in Anakinra-treated
rheumatoid arthritis patients
01.45-01.55 MRI of wrist and finger joints in patients with arthritis. Correlation
between dedicated extremity MRI (E-MRI) and clinical findings
01.55-02.05 Measurement of enhancing pannus volume in the hand in rheumatoid
arthritis (RA) using improved pst-minus pre-contrast-enhanced T1weighted MRI
02.05-02.15 Analysis of synovial microvascularization in patients with rheumatic
diseases using contrast ultrasound: preliminary results
02.15-02.25 Correlation of power Doppler sonography with vascularity of the
synovial tissue
02.25-02.35 Erosive early rheumatoid arthritis (RA) in finger and toe joints on
ultrasonography (US), Magnetic resonance imaging (MRI) and
conventional radiography (CR)
02.35-02.50 Epidural pannus as an underestimated cause of sub-axial cervical
spine stenosis in rheumatid arthritis.
E. Lindqvist
M. Østergaard
A. Savnik
E. Xanthopoulos
A. De Marchi
G. Labanauskaite
M. Szkudlarek
L.J.M. Kroft
Room 12, Saturday 14th June
Bone tumours and hemophilia, 8.00-10.00 am.
117
118
119
120
121
122
123
124
08.30-08.40 Dedifferentiated chondrosarcoma of the appendicular skeleton: MRIpathological correlation
08.40-08.50 Representativeness of radiologically guided fine-needle aspiration
biopsy of bone lesions
08.50-09.00 Combined radiology and cytology in the diagnosis of bone lesions. A
retrospective study of 370 cases
09.00-09.15 Whole-body MRI in primary malignant bone tumors using a moving
table top and comparison with bone scintigraphy
09.15-09.25 Imaging of bone forming tumors
09.25-09.35 Value of conventional radiography in detection of primary bone
tumours
09.35-09.45 Correlation between magnetic resonance (MRI) and ultrasound (US)
in the assessment of knee arthropathy in hemophilic children
09.45-10.00 A MR-score for hemophilic arthropathy
122
P.O’Donnell
V. Söderlund
V. Söderlund
C.R. Krestan
J.M. Park
C. Müller
Z. Czyrny
B. Lundin
Trauma and miscellaneous, 10.30-12.00 am.
125
126
127
128
129
10.30-10.45 CT for evaluation of rotational dislocation in supracondylar elbow
fractures
10.45-11.00 MRI in pediatric elbow trauma
11.00-11.10 MR imaging of avascular scaphoid nonunion after vascularized bone
grafting
11.10-11.20 Minimising dose in lumbar spine radiographs an audit
11.20-11.30 3D visualization of CT scans on handheld pocket computer, is it a
reality?
127
K. Jonsson
T. Pudas
S. Anderson
D.H. Taylor
H. Gregersen
130
Poster presentations at Room 11 and 12
130
131
132
133
134
Ultrasound imaging of joint disease
Costal chrondroid tumors mimicking intra-abominal masses.
Radiological and Pathological correlation
The use of MRI in diagnosis of occult hip fractures: A preliminary
revies
Differential diagnostic approach of CRMO: Chronic recurrent
multiplex opsteomyelitis
Pictorial review of diagnosis imaging techniques in following-up hip
arthroplasties
6
G. Groves
X. Tomás-Batlle
L.F. Foo
K. Kollo
P. Melloni Ribas
135
136
137
138
139
140
Abdominal metastases arising from bone sarcomas: Report of four
patients
Regional block in lower-limb: Value of imaging techniques
Musculoskeletal hemangioma from head to toe. MR imaging with
pathologic correlation
Anterior cruciate ligament tear associated injuries at MR imaging
CT-guided percutaneous biopsy of focal lesions in the thoracic spine
presenting a limited access route
Retrospective analysis of ultrasound guided core biopsy in the
diagnosis of soft tissue masses
7
J.Y. Kim
J.T. Pomés
J.C. Vilanova
G. Mantzikopoulos
G. Mantzikopoulos
F. J. Perks
Educational Lectures – Scandia Ballroom
th
Friday, 13th June 08.30 – 12.00 a.m. - Imaging of joints and inflammation – Course I
Chair: A. Cotten (F), M. Oestergaard (DK)
Abstract no. 1
GENERAL DIFFERENTIATION OF RADIOGRAPHIC FEATURES, AN OVERVIEW
A. Cotten
Service de Radiologie Ostéoarticulaire, Hôpital R Salengro, 59800 Lille, France
E-mail: [email protected]
Initial involvement of the hands, wrists and feet is frequent in infammatory joint diseases.
Consequently, a precise analysis of the pattern of arthritis distribution and of the radiographic
features may be helpful. The aim of this paper is to present the principal features allowing
differentiation.
Rheumatoid arthritis
In rheumatoid arthritis, radiographic findings include
− symmetric joint space involvement
− regional osteoporosis
− early diffuse joint space loss
− early marginal erosions (especially at the radial aspect of the second and third metacarpal heads,
at the styloid process of the ulna, and at the lateral aspect of the fifth metatarsal heads)
− sparing of the distal interphalangeal joints
− absence of bone proliferation
− deformities, extensive bone destruction, and fibrous or bony ankylosis (especially at the wrists)
in long-standing disease
Psoriatic arthritis
The articular manifestations of psoriatic arthritis include:
− frequent asymmetric or even unilateral articular distribution
− involvement of the distal and proximal interphalangeal joints, metacarpophalangeal and
metatarsophalangeal joints and calcaneus
− marginal erosions associated with bone proliferation. This latter feature is a striking feature of
psoriatic arthritis. It may take several forms: small irregular excrescences creating a spiculated,
frayed appearance; subchondral sclerosis; periostitis; ossifying enthesopathy
− joint space narrowing, or joint space widening due to a considerable subchondral bone
destruction (pencil-and-cup appearance)
− fusiform soft tissue swelling of a digit. The sausage-like swelling of entire digit is quite
suggestive of psoriasis
− intraarticular osseous fusion, especially at the interphalangeal joints
− tuftal resorption, malalignment and subluxation
Other frequent joint diseases
Inflammatory (erosive) osteoarthritis
Radiographic findings include:
− symmetric joint space involvement
− osteophytosis of the articular margins of the interphalangeal articulations
− erosions beginning in the central portion of these joints
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− joint space narrowing associated with subchondral sclerosis
− interphalangeal intra-articular bony ankylosis, rarely
Calcium pyrophosphate dihydrate crystal deposition disease
Radiographic findings include:
− articular and periarticular calcification: cartilage calcification (chondrocalcinosis), synovial,
capsular, tendon, bursa, ligament, and soft tissue calcification
− pyrophosphate arthropathy, which simulates degenerative joint disease with articular space
narrowing, bone sclerosis, and cyst formation, but it differs from degenerative joint disease in
several aspects:
− unusual articular and intra-articular distribution (elbow, radiocarpal joint, trapeziometacarpal
joint, talocalcaneonavicular joint)
− severe joint arthropathy with flattening, collapse and fragmentation of the bones and
extensive subchondral sclerosis.
− variable osteophyte formation. Joint space narrowing, sclerosis and fragmentation may be
unaccompanied by osteophyte formation.
− multiple subchondral cyst formation, in some cases.
Gout
As radiographic abnormalities in gouty joints appear late in the course of the disease, the diagnosis
usually is well established clinically. However, occasionally, the disease is not suspected prior to
radiographic examination. Radiographic findings of chronic tophaceous gout include:
− usually asymmetric joint involvement
− lobulated eccentric soft tissue masses (tophus)
− a well preservation of the joint space until late in the course of the disease. The preservation of a
relatively normal joint space despite extensive adjacent erosions is a characteristic feature of
gouty arthritis
− bony erosions that may be intraarticular or, more characteristically, para-articular or located at a
distance from the joint. They are dense as they contain thin calcifications and have frequently a
great size (greater of 5 mm). An elevated bony margin adjacent to the erosion and covering the
tophaceous nodule is suggestive
− usually absent regional osteoporosis
Reference
Resnick D. Diagnosis of bone and joint disorders. Saunders Company. 3ed. 1995.
Abstract no. 2
MRI OF PERIPHERAL JOINT ARTHRITIS WITH EMPHASIS ON SUBCHONDRAL BONE
AND CARTILAGE
C. Peterfy, M.D., Ph.D., H. Genant
Chief Medical Officer, Synarc, San Francisco, CA, USA
E.mail: [email protected]
Despite the advances made in medical imaging over the past three decades and the central role that
magnetic resonance imaging (MRI) and other sophisticated technologies now play in routine
clinical practice, patients with rheumatoid arthritis (RA) have benefited relatively little from these
advances thus far. Over the past few years, however, evidence has accumulated to show that MRI
can identify joint damage in patients with RA earlier and more sensitively than other techniques
can, and that these techniques can directly visualize and monitor changes in synovium and bone that
9
precede actual bone erosion. Much of this development is being driven by the pharmaceutical and
biotechnology industries as they search for novel therapies to combat this disease. Accordingly, the
imaging tools that ultimately will be used to direct patients to specific therapies and then to monitor
treatment effectiveness and safety are currently being refined and validated in rigorous multi-center
and multinational clinical trials aimed at gaining regulatory approval of these new therapies. As
these therapies become available for clinical use, we can anticipate increased demand for expertise
and experience in evaluating disease progression and treatment response with these techniques and
the emergence of MRI systems specifically adapted for this application. The following discussion
reviews the current status of this development, and points to areas where advances can be expected
in the near future.
Although radiography has dominated imaging evaluation of RA, the information it provides is
fundamentally limited in a number of ways. The most striking limitation is its inability to visualize
directly non-osseous features of disease. Bone erosion and joint-space narrowing are relatively well
delineated by radiography, but tend to develop late in course of the disease, progress slowly and
constitute irreversible structural damage. Also, the projectional viewing perspective of radiography
results in superimposition of overlapping structures, which can obscure erosions or simulate jointspace narrowing (1). Even with the use of optimal radiographic technique, high-detail film, scoring
methods specially designed for monitoring progression, and highly trained, experienced readers, at
least six to 12 months are needed to resolve a difference in disease progression between patients
treated with active structure-modifying therapy and those treated with placebo or active control in
multi-center clinical trials. This makes it extremely costly to test putative new therapies for RA and
difficult to manage patients in clinical practice.
MRI offers a number of advantages over conventional radiography for evaluating structural damage
to the joints in RA (1). The tomographic viewing perspective of MRI obviates projectional
superimposition, which can obscure erosions and mimic joint-space narrowing on conventional
radiographs. The ability to visualize also bone marrow, synovium, articular cartilage, ligaments and
tendons allows the joint to be examined as a whole organ and for early manifestations of the disease
to be detected before irreversible damage becomes demonstrable by radiography. Several studies
have shown MRI to be two or more times as sensitive as radiography (2-13) or ultrasound (13) for
detecting bone erosions. This advantage of MRI has been demonstrated not only with conventional
1.5T MRI but also with low-field (0.2T) MRI (12,13), which can image joints at a fraction of the
cost of conventional MRI (14). By tracking individual erosions seen on MRI at baseline in patients
with early (< 6 months) RA, McQueen, et al. (11) was able to demonstrate the gradual appearance
of many of these erosions at exactly the same location on radiographs one and two years later.
In early RA, the greater sensitivity of MRI for detecting bone erosions could be leveraged to
identify patients who were most likely to progress and therefore in need of aggressive therapy. In
clinical trials, this could be useful for enriching the study group with rapid progressors, or
increasing the statistical power for demonstrating differences in disease progression and treatment
response between active treatment arms.
In Conclusion, as effective structure-modifying therapies for RA begin to enter mainstream clinical
practice, and early aggressive therapy becomes more widespread, the utility of conventional
radiography in the management of RA patients will continue to diminish, and an increased demand
for MRI can be anticipated.
1. Peterfy C. Imaging Techniques. In: Klippel J, Dieppe P, eds. Rheumatology 2E. Vol. 1. Philadelphia:
Mosby, 1997:14.1-14.18.
2. Jorgensen C, Cyteval C, Anaya J, Baron M, Lamarque J, Sany J. Sensitivity of magnetic resonance
imaging of the wrist in very early rheumatoid arthritis. Clin Exp Rheumatol 1993; 11:163-168.
3. McQueen F, Stewart N, Crabbe J, et al. Magnetic resonance imaging of the wrist in early rheumatoid
arthritis reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis 1998;
57:350-360.
4. Peterfy C, Dion E, Miaux Y, et al. Comparison of MRI and X-ray for monitoring erosive changes in
rheumatoid arthritis. Arthritis Rheum 1998; 41 (Suppl):S51.
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5. Østergaard M, Hansen M, Stolenberg M, et al. Magnetic resonance imaging-determined synovial
membrane volume as a marker of disease activity and a predictor of progressive joint destruction in the
wrists of patients with rheumatoid arthritis. Arthritis Rheum 1999; 42:918-929.
6. Klarlund M, Østergaard M, Gideon P, Sorensen K, Hendriksen O, Lorenzen I. Wrist and finger joint MR
imaging in rheumatoid arthritis. Acta Radiol 1999; 40:400-409.
7. Foley-Nolan D, Stack J, Ryan M, et al. Magnetic resonsnce imaging in the assessment of rheumatoid
arthritis - a comparison with plain film radiographs. Br J Rheumatol 1991; 30:101-106.
8. McGonagle D, Conaghan PG, O'Connor P, et al. The relationship between synovitis and bone changes in
early untreated rheumatoid arthritis: a controlled magnetic resonance imaging study. Arthritis Rheum
1999; 42:1706-1711.
9. Østergaard M, Gideon P, Sorenson K, et al. Scoing of synovial membrane hypertrophy and bone
erosions by MR imaging and clinically active and inactive rheumatoid arthritis of the wrist. Scand J
Rheumatol 1995; 24:212-218.
10. Emery P, Luqmani R. The validity of surrogate markers in rheumatic disease. Br J Rheumatol 1993; 32
Suppl 3:3-8.
11. McQueen FM, Benton N, Crabbe J, et al. What is the fate of erosions in early rheumatoid arthritis?
Tracking individual lesions using x-rays and magnetic resonance imaging over the first two years of
disease. Ann Rheum Dis 2001; 60:859-868.
12. Lindegaard H, Vallø J, Høslev-Petersen K, Junker P, Østergaard M. Low field dedicated magnetic
resonance imaging in untreated rheumatoid arthritis of recent onset. Ann Rheum Dis 2001; 60:770-776.
13. Backhaus M, Burmester GR, Sandrock D, et al. Prospective two year follow up study comparing novel
and conventional imaging procedures in patients with arthritic finger joints. Ann Rheum Dis 2002;
61:895-904.
14. Peterfy CG, Roberts T, Genant HK. Dedicated extremity MRI: an emerging technology. In: Kneeland
JB, ed. Radiol Clin N Am. Vol. 35. Philadelphia, PA: W.B. Saunders, 1996:1-20.
Abstract no. 3 – not submitted
ASSESSMENT OF VASCULARITY, PERFUSION AND ANGIOGENESIS WITH
RADIOLOGICAL METHODS – APPLICATION ON JOINT INFLAMMATION
M. Reiser, MD
Klinik Grosshadern, Ludwig-Maximilian University München, München, Germany
Abstract no. 4
ASSESSMENT OF OSTEOPOROSIS IN INFLAMMATORY ARTHRITIS
H. K, Genant, M. Grigorian, A. Mohr, F. Roemer
OARG, University of California, San Francisco
In the past decade, considerable progress has been made in the development of methods for
quantitatively assessing the skeleton, so that osteoporosis can be detected early, its progression and
response to therapy carefully monitored, and the risk of fracture effectively ascertained. Clinicians
can now evaluate the peripheral, central or entire skeleton as well as the trabecular bone or cortical
bone envelopes with a high degree of accuracy and precision, and they have the capacity to estimate
bone strength and fracture risk. There are a variety of techniques currently available for
noninvasive assessment of the skeleton: radiographic absorptiometry (RA), single x-ray
absorptiometry (SXA), dual x-ray absorptiometry (DXA), spinal and peripheral quantitative
computed tomography (QCT/pQCT), and quantitative ultrasound (QUS). These techniques vary in
precision, accuracy and discriminative capability, and differ substantially in fundamental
11
methodology, in clinical and research utility, and in general availability. While these techniques
have generally focused on postmenopausal osteoporosis, idiopathic male osteoporosis and
osteoporosis of the elderly, there is increasing application in other forms of secondary osteoporosis
including that associated with rheumatoid arthritis (RA). In the latter application, both conventional
BMD measures of the central and peripheral skeleton and specialized approaches quantifying periarticular BMD in the hands have been on assessed.
Osteoporosis of the axial and appendicular skeleton has long been recognized in patients with RA.
The localized osteoporosis seen around inflamed joints is one of the earliest articular manifestations
of RA seen on radiographs and is used in the American Rheumatism Association diagnostic criteria.
Generalized bone loss in the axial skeleton has been suggested to be one of the most common extraarticular manifestations of the disease. The pathogenesis of osteoporosis in RA is multi-factorial.
Several factors, such as inactivity or disuse and cellular mediators of inflammation as well as antirheumatic medication such as corticosteroids, are important in the peri-articular and generalized
bone loss. Recent studies have shown that pro-inflammatory cytokines stimulate the expression of
osteoprotegerin ligand (OPGL), a protein of the tumor necrosis factor (TNF) ligand superfamily, on
synoviocytes and activated T cells. Osteoprotegerin ligand stimulates osteoclast formation and
activation, leading to osteoporosis (as well as erosions).
Bone densitometry of the peripheral and central skeleton is an objective and precise method for
monitoring this form of secondary osteoporosis. Bone loss is more rapid in patients with early
rheumatoid arthritis and correlates well with measures of inflammation and function. Data are
emerging that monitoring bone loss of the hands in early rheumatoid arthritis could be an outcome
measure and a prognostic indicator of future functional disability. Suppressing inflammation
effectively with the newer biological agents such as TNF alpha, OPGL and Interlukin-1 blockers,
and reducing bone resorption with bone active agents such as estrogen and bisphosphonates can
ameliorate the ravages of osteoporosis in this disorder.
This review will assess the current capabilities of the available bone densitometry methods and their
recent technical advances, and will review the application of these techniques to the study of periarticular and generalized osteoporosis in rheumatoid arthritis.
References
1. Deodhar AA, Brabyn J, Jones PW, Davis MJ, Woolf AD. Longitudinal study of hand bone densitometry
in rheumatoid arthritis. Arthritis Rheum 1995;38:1204–10.
2. Gough AKS, Lilley J, Eyre S, Holder RL, Emery P. Generalised bone loss in patients with early
rheumatoid arthritis. Lancet 1994;344:23–7.
3. Sambrook PN, Eisman JA, Champion GD, Yeates MG, Pocock NA. Determinants of axial bone loss in
rheumatoid arthritis. Arthritis Rheum 1987;30:721–8.
4. Shenstone BD, Mahmoud A, Woodward R, Elvins D, Palmer R, Ring EF, et al. Longitudinal bone
mineral density changes in early rheumatoid arthritis. Br J Rheumatol 1994;33:541–5.
5. Hansen M, Florescu A, Stoltenberg M, Pødienphant J, Pedersen-Zbinden B, Hørslev-Petersen K, et al.
Bone loss in rheumatoid arthritis. Scand J Rheumatol 1996;25:367–76.
6. F. E. Alenfeld, E. Diessel, M. Brezger, J. Sieper, D. Felsenberg and J. Braun. Detailed Analyses of
Periarticular Osteoporosis in Rheumatoid Arthritis. Osteoporos Int (2000) 11:400–407.
7. Eric-Jan J. A. Kroot, Mieke G. Nieuwenhuizen, Maarten C. de Waal Malefijt, Piet L. C. M. van Riel,
Pieternel C. M. Pasker-de Jong, and Roland F. J. M. Laan. Change in Bone Mineral Density in Patients
With Rheumatoid Arthritis During the First Decade of the Disease. Arthritis Rheum 2001Vol. 44, No. 6,
pp 1254–1260 Bone changes in early rheumatoid arthritis.
8. Michael J. Green, Atul A. Deodhar, Bone changes in early rheumatoid arthritis. Best Practice &
Research Clinical Rheumatology Vol. 15, No. 1, pp. 105±123, 2001.
9. Devlin, J., et al., Clinical associations of Dual-energy X-ray absorptiometry measurement of hand bone
mass in rheumatoid arthritis. Brit J Rheumatol, 1996;35: 1256-62.
10. Glenn Haugeberg,1 Ragnhild E. Ørstavik, Till Uhlig,1 Jan A. Falch, Johan I. Halse and Tore K. Kvien.
Bone Loss in Patients With Rheumatoid Arthritis Results From a Population-Based Cohort of 366
Patients Followed Up for Two Years. Athritis & Rheumatism Vol. 46, No. 7, July 2002, pp 1720–1728.
12
11. Peel NF, Spittlehouse AJ, Bax DE, Eastell R. Bone mineral density of the hand in rheumatoid arthritis.
Arthritis Rheum 1994 Jul;37(7):983-91.
12. B J Harrison, C E Hutchinson, J Adams, I N Bruce, A L Herrick. Assessing periarticular bone mineral
density in patients with early psoriatic arthritis or rheumatoid arthritis Ann Rheum Dis 2002;61:1007–
1011.
13. A. L. Dolan, C. Moniz1, H. Abraha1 and P. Pitt. Does active treatment of rheumatoid arthritislimit
disease-associated bone loss? Rheumatology 2002;41:1047–1051.
14. J. Iwamoto, T.Takeda, S. Ichimura. Forearm Bone Mineral Density in Postmenopausal Women with
Rheumatoid Arthritis. Calc Tissue Int, 2002 70:1-8.
15. Vivek Swarnakar, Bo Fan, Harry K. Genant. Automated radiographic absorptiometry system for
quantitative rheumatoid arthritis assessment. Proc. SPIE Vol. 4322, p. 1924-1935, Medical Imaging
2001: Image Processing, Milan Sonka; Kenneth M. Hanson; Eds.
16. Genant H.K., Fuerst T., et. al., Noninvasive assessment of bone mineral and structure: state of the art. J.
Bone and Min Res.; 1996;11:707-730.
Abstract no. 5
THERAPEUTIC AND DIAGNOSTIC ULTRASOUND
Eugene G. McNally
Nuffield Orthopaedic Centre, Oxford UK
Ultrasound is an ideal method for guiding interventional musculoskeletal procedures. In the
majority of cases a 21 gauge needle is all that is necessary to puncture the majority of relatively
superficial musculoskeletal structures. Complex preparation is not required and with sensible
attention to sterility, extra-articular soft tissue injections have a remarkably low complication
profile when placed in their intended locations. A preliminary examination locates the intended
target structure and approach route. For very superficial structures, a small footprint probe
approximates the puncture point and target and is ideal for guiding the injection of small joints of
the hand or foot. The puncture point can be marked in variety of ways. Traditionally skin marking
pens are used but have the slight disadvantage of either being wiped clear during skin sterilisation if
they are water soluble or smearing and staining the probe if not. Pressure with the blunt end of a
needle or needle cover avoids this. The author prefers to use a marking line rather than a point as
this not only gives a puncture point but an initial needle direction. With practice, this means that the
needle can be inserted to close to its destination blind. When the probe is then replaced onto the
skin, the needle can be advanced the final distance to its intended target. A line can be created either
with a skin marking pen, or by pressure from an extended paperclip. Pressing for or ten seconds
produces an impression that lasts about five minutes, plenty of time for scrubbing and kin
preparation. Combining skin pressure and a marker pen is another alternative. In some cases, it is
not even necessary to remove the probe during skin preparation. For SASD bursal injections for
example, the shoulder examination sequence can end with the probe in the correct position for
injection. A quick wipe with a sterile swab is followed by the bursal injection. In this way a
diagnostic procedure can be combined with a guided injection with little prolongation of the
examination time. In children, the use of a topical local anaesthetic cream or ethyl chloride spray or
both helps to reduce even the small initial discomfort of the initial injection. These can also be used
in adults in areas that are more uncomfortable such as the sole of the foot. Whether they provide
any more than placebo effect in adults is questionable. The sting from some anaesthetic
preparations can also be reduced by the addition of a 1% bicarbonate solution.
The patient experience can also be improved by careful attention to a number of small but
thoughtful details. The injection trolley should be prepared in advance if possible and be kept out of
view until needed. It is unnecessary to draw up drugs in full view of the patient. Ideally the patient
13
should not see a needle until the moment it is to be inserted into the skin. Adequate time should be
given for local anaesthesia to work. When more complex preparations are necessary, it is suggested
that skin preparation and local anaesthesia injection are carried out prior to the application of a
sterile probe cover. Any minor distraction at the precise moment of needle insertion, such as asking
the patient to take a breath or directing a question can help. Particular attention to the needs of
children with familiar personnel, parents, nurses and play therapist as necessary can improve the
experience and reduce the future development of needle phobia.
The injection cocktail most frequently used is a combination of a corticosteroid mixed with a local
anaesthetic. Either long or short acting local anaesthetics can be used. The author’s preference is for
a combination of Triamcinolone 40mgs mixed with 0.5% Bupivicaine. For more superficial
injections where there is significant risk of subcutaneous leak, Depomedrone replaces
Triamcinolone as the corticosteroid of choice. There is some evidence to suggest that this
preparation is less prone to cause subcutaneous fat necrosis.
In all cases care should be taken not to inject corticosteroid directly into tendons as an area of focal
necrosis may lead to tendon rupture. With practice there is little difficulty but for those less certain
about correct needle placement, a preliminary injection of a small quantity of local anaesthetic on
its own can be helpful to distend the tendon sheath and confirm correct needle placement. Local
anaesthetics are less damaging to tendons than corticosteroid but in all cases it is unwise to continue
with injection when undue pressure is encountered.
SPECIFIC TECHNIQUES
The following techniques will be discussed:
SUBACROMIAL SUBDELTOID BURSAL INJECTION
SUPRASPINATUS CALCIFICATION BARBOTAGE
ACROMIOCLAVICULAR JOINT INJECTION
COMMON EXTENSOR ORIGIN
INTRA-ARTICULAR INJECTION ELBOW
TENDON SHEATH INJECTION
CARPAL TUNNEL INJECTION
INJECTION OF SMALL JOINT OF THE HAND
ASPIRATION OF THE INFANT HIP
ASPIRATION AND INJECTION OF THE ADULT HIP
HIP BURSAL INJECTION
ADDUCTOR ORIGIN AND SYMPHOSEAL INJECTION
KNEE JOINT ASPIRATION AND SYNOVIAL BIOPSY
PROXIMAL TIBIO-FIBULAR JOINT
ACHILLES BURSA
PLANTAR FASCIA
MORETON’S NEUROMA INJECTION
FOREIGN BODY LOCALISATION
SOFT TISSUE AND BONE BIOPSY
Abstract no. 6
Jorn Theil Nielsen, MD, DMSc
Dept. Of Nuclear Medicine, Aarhus University Hospital, Aarhus, Denmark.
NUCLEAR MEDICINE EXAMINATIONS IN INFLAMMATORY DISEASES
14
Radiopharmaceuticals have been used to detect synovitis activity since the mid-fifties. The most
widely used radiopharmaceuticals for bone and joint imaging are Tc-99m diphosphonates. The
increased uptake in inflammatory joint disease is caused by increased blood flow and new bone
formation due to increased osteoblastic activity. The method is very sensitive and may often be
positive before changes are seen in X-ray images, but the increased uptake may be also be caused
by various other non-inflammatory diseases.
Several other radiopharmaceuticals have and is being used for visualization of inflammatory
processes.
The radiopharmaceutical 67Ga-citrate binds to the iron-binding proteins transferrin and ferritin and
the complex accumulates in inflamed synovial tissue but the uptake is not well correlated to the
inflammatory activity and the physical characteristics of the isotope are undesirable.
Leukocytes labeled with 111In-Tropolone or 99mTc-HMPAO may accumulate not only in inflamed
synovial membranes but also in joints with osteoarthritis.
The colloid 99mTc-Nanocoll leak through the fenestrations of the capillaries and thus may
accumulate in inflamed joints. 99mTc-Nanocoll also correlates better with the degree of
inflammation than diphosphonates.
Polyclonal immunoglobulins labeled with 111In or 99mTc have been used for imaging of
inflammation and is more specific than diphosphonates. However, it also accumulates in joints not
clinically involved.
Some of the latest experimental methods use Tc-99m Annexin-V for detection of cells marked for
apoptosis as an effect of the inflammatory processes.
Abstract no. 7
DIFFERENTIATION AT IMAGING BETWEEN RHEUMATOID AND SERONEGATIVE
ARTHRITIS
Wilfred C.G. Peh, MBBS, MD, FRCPG, FRCPE, FRCR
Senior Consultant Radiologist, Singapore Health Services
Clinical Professor, National University of Singapore
Email: [email protected]
Rheumatoid arthritis is a systemic inflammatory disease that is characterised by a typical pattern
and distribution of synovial joint involvement. Diagnosis of RA is made by a combination of
clinical, radiographical and laboratory criteria, including a positive rheumatoid factor. Another large
group of inflammatory arthritides are classified as seronegative (i.e. negative rheumatoid factor).
These are also known as seronegative spondyloarthopathies and include related disorders such as
ankylosing spondylitis, psoriatic arthropathy, Reiter syndrome, enteropathic arthropathy and
juvenile chronic arthritis. Diagnosis of the seronegative spondyloarthropathies is made by a
combination of clinical, radiographical and laboratory criteria, with a strong association with the
HLA-B27 gene in this group. The differentiation at imaging between these two groups is
highlighted.
Rheumatoid arthritis typically involves multiple joints, with a bilateral and symmetrical pattern of
distribution. The small joints of the hands, namely the metacarpophalangeal and proximal
interphalangeal joints, and wrist are particularly affected. Other sites are the feet, knees, ankles,
elbows, glenohumeral and acromioclavicular joints, and the hips. Synovial articulations of the axial
skeleton, especially the apophyseal and atlantoaxial joints of the cervical spine, are also frequently
affected. The sacroiliac joint is rarely involved. The cartilaginous articulations and the entheses are
typically less frequently and less severely affected.
15
In rheumatoid arthritis, initial synovial inflammation and effusion results in soft tissue swelling and
joint space widening, followed by periarticular osteoporosis. Pannus formation causes cartilage
destruction, periarticular erosions and subchondral bone destruction. Capsular and ligamentous
laxity produces joint subluxation or dislocation. There may be eventual fibrosis and bony ankylosis.
Periosteal reaction is uncommon. Complications include deformity, tendon rupture and cord
compression due to cervical subluxation.
Seronegative arthropathies typically affect the spine and sacroiliac joints. The peripheral synovial
joints are affected to a lesser degree. The pattern of involvement is usually an asymmetrical
oligoarthritis. Osteoporosis is less marked, compared to rheumatoid arthritis. Periosteal reaction and
syndesmophytes are features that are not usually found in rheumatoid arthritis.
Ankylosing spondylosis (AS) is the prototypical seronegative spondyloarthropathy. This chronic
and progressive disease is characterised by inflammation of multiple articular and para-articular
structures, frequently resulting in bony ankylosis. AS typically affects the axial skeleton, with a
predilection for the sacroiliac and spinal facet joints, and paravertebral soft tissues. AS primarily
afflicts the entheses, with inflammation, calcification and ossification. Enthesopathic sites include
the iliac crest, ischial tuberosity, greater trochanter and calcaneum. In the spine, new bone
formation at the outer layer of the annulus fibrosis or syndesmophyte occurs. Radiographical
changes in the peripheral joints are a feature of long-standing AS. Complete fusion of the vertebra
by syndesmophytes and other related ossified areas produces a bamboo spine. Spinal fractures and
pseudoarthrosis are complications of established AS.
Psoariatic arthropathy may be classified into five clinical and imaging patterns. Generally, the
common subtypes of psoriatic arthropathy tend to produce only mild erosive disease. Hand and foot
joint involvement is typically asymmetrical, and have a predilection for distal interphalangeal joints.
Reiter syndrome is a form of reactive arthritis and is triggered by a bacteria infection, classically
urethritis and conjunctivitis. There is a marked male predominance. The pattern of an asymmetrical
oligoarticular erosive arthritis is more common in the lower extremities, with periosteal new bone,
enthesopathy, sacroiliitis and spondyloarthropathy also occurring. The enteropathic arthropathies
share many of the imaging features of the other seronegative spondyloarthropathies.
In summary, pattern recognition of the imaging features is essential for differentiating rheumatoid
arthritis from seronegative spondyloarthropathies. Many of these seronegative arthropathies also
have distinct clinical features that aid diagnosis.
16
th
Friday, 13th June 01.00 – 02.50 p.m. – Rheumatooid arthritis (RA) – Course II
Chair: I. McCall (UK), A. Cotten (F)
Abstract no. 8
CLINICAL ASPECTS OF RHEUMATOID ARTHRITIS
K. Stengaard-Pedersen
Dept.of Rheumatology, Aarhus University Hospital, Denmark
Clinical aspects of pathogenesis, prediction of aggressive disease, monitoring of signs and
symptoms, and the future treatment of rheumatoid arthritis will be highlighted.
The hallmarks of the pathogenesis are inflammation, abnormal immune response, angiogenesis and
synovial hyperplasia. Abnormalities in the cytokine network of importance for the clinical signs and
symptoms will be focused on.
Many possible prognostic factors have been identified. Next to genetic factors (shared epitope)
several serological tests as rheumatoid factor, anti peri-nuclear factor, anti-keratin antibodies, and
anti-citruline-containing peptide antibodies have been shown to have some prognostic value to
predict radiological damage or functional disability.
The therapy for rheumatoid arthritis is still far away from offering long-term remission or cure.
During the last decades the need for early application and the use of combinations of DMARDs
have proven to be successful. Recent evidences have suggested an imbalance at the site of
inflammation in rheumatoid arthritis whereby proinflammatory cytokines outnumber antiinflammatory cytokines or natural inhibitors. This has resulted in the investigation of therapies that
aim to restore this imbalance. The progression of the clinical development of TNF-blockage in
rheumatoid arthritis has been impressive.
Abstract no. 9
IMAGING IN RHEUMATOID ARTHRITIS: THE UPPER EXTREMITY
Javier Beltran, M.D.
Dept. of Radiology, Maimonides Medical Center, Brooklyn, New York, USA
Purpose of Imaging:
• Early diagnosis
• Staging
• Determine efficacy of treatment
Imaging techniques in RA:
• Conventional radiogrpahy
• Ultrasponography
• Scintigraphy
• CT
17
•
MRI
Conventional Radiography:
• Acute synovitis
− Effusion, capsular distension, soft tissue swelling, joint space widening
• Hyperemia
− Regional or periarticular osteoporosis
• Pannus formation and cartilage damage
− Narrowing joint space
− Central and marginal erosions
− Subchondral cysts, synovial cysts, sinus tracts
• Fibrous and osseous ankylosis, entheses
• Capsular, ligamentous laxity, muscular contraction
− Deformity, subluxation, insufficiency fractures, fragmentation, sclerosis, secondary
osteoarthritis
Hand and Wrist lesions in RA:
Bony Erosions in RA:
• Marginal (Pannus in bare areas)
− MCP, PIP, radial styloid, mid scaphoid, triquetrum, capitate, trapezium
• Compressive (Collapse of bone and muscular forces)
− MCP
• Surface resorption (Erosion beneath inflamed tendon)
− Distal ulna, distal 1st metacarpal, proximal phalanx first digit
Finger Deformities in RA:
• Mallet finger (flexion DIP)
• Boutonnière deformity (flexion PIP, hyperextension DIP)
• Swan-Neck deformity (hyperextension PIP, flexion DIP)
• Ulnar deviation (MCP)
• Hitchhiker’s thumb (hyperextension IP, flexion MCP)
Wrist Deformities in RA:
• Swelling and erosions ulnar styloid
• Erosions distal radioulnar compartment and volar distal radius
• Tenosynovitis ECU
• Radioscaphoid erosions
• Erosions piso-triquetral joint
• Intrarticular osseous fusion
• Radiocarpal and intercarpal malalignement (ulnar migration of the carpus, DISI, VISI)
• Dorsal subluxation of the ulna
Conventional Radiography - Hand and wrist: scoring systems
• Larsen A et al. Acta Radiol Diagn Stockh1977;18:481-491
• Genant H et al. Arthritis and Rheum 1998;41:1583-1590
• Good intra and inter observer agreement
• Insensitive in detecting early erosions, synovitis
Elbow Lesions in RA:
• Effusion, soft tissue swelling
• Joint space narrowing
• Bony erosions
− Radial head, coronoid process, distal humerus
18
•
•
•
Extensive osteolysis
Cysts
Fractures
Shoulder Lesions in RA
• Joint space narrowing, erosions
• Subchondral cyst, greater tuberosity
• Deformity and flattening humeral head
• Pressure erosions surgical neck
• Superior migration humeral head (RCT)
• Synovial cysts
• Erosions AC joint, distal clavicle
• Erosions sternoclavicular joint
Ultrasound and MRI:
• Effusion (US-guided injection)
• Tenosynovitis, tendon ruptures
• TFC tears, destruction
• Small and early erosions
• Synovial cysts, bursitis
• Pannus formation
• Villi
• Rice bodies
• Rheumatoid nodules
• Early cartillage thinning (MRI)
• Subchondral cysts (MRI)
• Assessment of responders vs. non-responders
US vs. MRI:
• Ciechomsska et al. Pol Merkuriusz 2001;11:14-147
− 61 patients
− Both showed bone erosions, synovitis, better than conventional radiography
Power Doppler US:
• Szkudlarek M. et al. Arthritis and Rheum 2001;44: 2018-2023
− 54 MCP joints in RA and12 MCP joints in normals
− Dynamic MRI as reference
− PDUS reliable in assessing inflammatory activity
CR vs. BS vs. US vs. Dynamic 3D MRI:
• Backhaus M et al. Ann Rheum Dis 2002;61:895-904
− 2 year follow up study finger joints, 49 patients
− 3D MRI best for erosions
− US sensitive for soft tissue inflammation
− CR inadequate for small erosions, inflammation
− BS showed decreased uptake correlating with clinical improvement
CR vs. BS vs. US vs. Contrast MRI:
• Backhaus M et al. Arthritis and Rheum 1999;42;1232-1245
− US, MR and BS more sensitive than CR in detecting inflammatory soft tissue lesions
19
− US better than MRI for synovitis
− MRI best for erosions
MRI better than CR for Bone Erosions:
• Klarlund M et al. Ann Rheum 2000;59:521-528
• Hopfner et al. Nuklearmedizin 2002;41:135-142
Bone Scintigraphy:
• Mapping joint involvement (Whole body)
• Exclude inflammation
• Tc99m-labelled anti-E-selectin Fab fragment (targets activated endothelium)
− Jamar F et al. Rheumatology 2002; 41:53-61
Better specificity than Tc99m-HDP for synovitis
• Radioisotopic synoviorthesis with 90Y silicate
MRI in RA. Advantages:
• Earlier detection of joint damage
• Monitor changes in synovium and bone
“Rice Bodies”
• Synovial Chondromatosis
• Rheumatoid Arthritis
• Tuberculosis
References
1. Klarlund M et al. Magnetic resonance imaging, radiography, and scintigraphy of the finger joints: one
year follow up of patients with early arthritis. The TIRA Group. Ann Rheum 2000;59:521-528
2. Hopfner et al. Diagnosis of initial changes in the hand of patients with rheumatoid arthritis - comparison
between low-field magnetic resonance imaging, 3-phase bone scintigraphy and conventional x-ray.
Nuklearmedizin 2002; 41:135-142
3. Jamar F et al. Scintigraphy using a technetium 99m-labelled anti-E-selectin Fab fragment in rheumatoid
arthritis. Rheumatology 2002; 41:53-61
4. Backhaus M et al. Arthritis of the finger joints: a comprehensive approach comparing conventional
radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis and
Rheum 1999; 42;1232-1245
5. Backhaus M et al. Prospective two year follow up study comparing novel and conventional imaging
procedures in patients with arthritic finger joints. Ann Rheum Dis 2002;61:895-904
6. Szkudlarek M. et al. Power Doppler ultrasonography for assessment of synovitis in the
metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic
resonance imaging. Arthritis and Rheum 2001;44:2018-2023
7. Ciechomsska A. Andrysiak R, Serafin-Krol M, Tlustochowicz W, Cholewa M. The assessment of the
value of ultrasound and magnetic resonance imaging in diagnosing hand joint arthritis. Pol Merkuriusz
2001;11:14-147
8. Larsen A et al. Acta Radiol Diagn Stockh1977;18:481-491
9. Genant H et al. Arthritis and Rheum 1998;41:1583-1590
10. Perez Velasco R, Hervas Benito I. Quantification of bone scintigraphy as an objective method in the
follow-up of radioisotopic synoviorthesis. Rev Esp Med Nucl 2002 Nov-Dec;21(6):426-32
11. Szkudlarek M et al. Contrast-enhanced power Doppler ultrasonography of the metacarpophalangeal
joints in rheumatoid arthritis. Eur Radiol 2003; 13(1):163-8
12. Backhaus M, Sandrock D, Schmidt WA. Imaging in rheumatology. Dtsch Med Wochenschr
2002;127(37):1897-903
13. Ostergaard M, Szkudlarek M. Magnetic resonance imaging of soft tissue changes in rheumatoid arthritis
wrist joints. Semin Musculoskelet Radiol 2001;5(3):257-74
20
14. Peterfy CG Magnetic resonance imaging of the wrist in rheumatoid arthritis. Semin Musculoskelet
Radiol 2001;5(3):275-88
15. D'Agostino MA, Breban M. Ultrasonography in inflammatory joint disease: why should rheumatologists
pay attention?. Joint Bone Spine 2002;69(3):252-5
16. Backhaus M. Value of arthrosonography in early arthritis diagnosis. Z Rheumatol 2002;61(2):120-9
17. Sell S, Martini F, Sell I. Ultrasound diagnosis of inflammatory diseases of the hand and elbow.
Orthopade 2002;31(3):278-81
18. Stone M, Bergin D, Whelan B, Maher M, Murray J, McCarthy C. Power Doppler ultrasound assessment
of rheumatoid hand synovitis. J Rheumatol 2001;28(9):1979-82
19. Hau M, Kneitz C, Tony HP, Keberle M, Jahns R, Jenett M. High resolution ultrasound detects a decrease
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Abstract no. 10
IMAGING RHEUMATOID ARTHRITIS OF THE LOWER LIMB
P J O’Connor, FRCR
Dept. of Radiology, The Leeds Teaching Hospitals Trust, Leeds LS1 3EX, UK
E-mail: Philip.O’[email protected]
MRI and ultrasound have an increasingly prominent role in the assessment of articular disease. This
lecture focuses specifically upon the assessment of Rheumatoid Arthritis of the lower limb.
Rheumatoid arthritis (RA) is a chronic inflammatory polyarthritis characterised by synovitis and
joint destruction, particularly of the small joints. Studies have shown progression of joint
destruction despite suppression of synovitis. Other studies indicate that despite no change in clinical
synovitis measures, certain therapies retard bone damage. More recently it has been demonstrated
that the suppression of disease activity will slow or even halt progression of bone damage although
there was poor correlation between clinical response and radiological change in these studies. Such
clinical and radiographic observations where synovitis and bone damage are seemingly independent
processes have been supported by experimental models of RA where joint damage may be
uncoupled from synovitis. However, all studies have used either indirect or insensitive measures of
synovitis and bone damage or have imaged complex joints such as the wrist, which makes
interpretation of any imaging findings difficult. An understanding of the inter-relationship between
synovitis and bony damage is critical for the optimal management of patients, especially in
determining a logical approach for drug treatment, and provides the model for all disease where
chronic inflammation is a prominant feature.
This lecture focuses on the use of MRI and Ultrasound in the assessment of lower limb Rheumatoid
disease with specific emphasis on the detection and potential impact of diagnosing subclinical
synovitis, pre-radiographic erosion and complications. A list of relevant references is provided.
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glenoid labrum: a cadaveric study with arthroscopic correlation. AJR Am J Roentgenol
2000;174(6):1717-22.
Tasker AD, Ostlere SJ. Relative incidence and morphology of lateral and medial meniscal cysts
detected by magnetic resonance imaging. Clin Radiol 1995;50(11):778-81.
Teefey SA, Middleton WD, Yamaguchi K. Shoulder sonography. State of the art. Radiol Clin North
Am 1999;37(4):767-85, ix.
Tirman PF, Feller JF, Janzen DL, Peterfy CG, Bergman AG. Association of glenoid labral cysts with
labral tears and glenohumeral instability: radiologic findings and clinical significance. Radiology
1994;190(3):653-8.
26
122. Tung GA, Entzian D, Stern JB, Green A. MR imaging and MR arthrography of paraglenoid labral
cysts. AJR Am J Roentgenol 2000;174(6):1707-15.
123. van Dijk CN, Mol BW, Lim LS, Marti RK, Bossuyt PM. Diagnosis of ligament rupture of the ankle
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124. Wakefield RJ, Brown AK, O'Connor PJ, Emery P. Power Doppler sonography: improving disease
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Abstract no. 11
RHEUMATOID ARTHRITIS – ARTHRITIS OF THE CERVICAL SPINE.
Iain W. McCall, MD
Dept. of Diagnostic Radiology, Robert Jones & Agnes Hunt Orthopaedic & District
Hosp. NHS Trust Oswestry, Shropshire SY 10 7AG, UK
e-mail: [email protected]
The cervical spine is the second most commonly affected anatomical region in Rheumatoid arthritis
and the severity of cervical spine involvement correlates with the duration and severity of the
systemic process being commoner with severe peripheral arthritis, nodules and high-titre
rheumatoid factor. The initial phase of the disease involves hypertrophic, hyperactive inflammatory
synovium that causes ligamentous destruction and subsequent hypermobility. Severe mechanical
degeneration is then superimposed on the hypermobile spine and may result in cord and nerve root
compression although neurological deficit only occurs in 7- 13% of patients. Rheumatoid arthritis
may also have vascular consequences resulting in cord ischaemia resulting in further neurological
deficit.
Investigation of the cervical spine in rheumatoid arthritis is usually initially undertaken by anteroposterior and lateral radiographs in flexion and extension. Synovial hypertrophy will not be
identified but the erosive stage is demonstrated by irregularity of the odontoid peg and marginal
erosions with joint space narrowing of the facet joints.Erosive changes are also seen in the
vertebral end plates which may be localised or widespread and associated with disc space narrowing
and end plate sclerosis. The spinous processes may vary from finely etched bone destruction to
extensive bone loss giving a sharpened pencil appearance. Atlanto-axial subluxation is most
commonly present with the majority anterior but 20% are lateral and 10% posterior. The normal
maximal width of the preodontoid space in an adult is 3mm but abnormal measurements have not
been shown to be predictive of neurology as a 10mm interval would have only detected 35% of
those patients with paralysis. Narrowing of the posterior atlanto-dental interval to less than 14mm
however correlated with the onset of severe paralysis and less than 10mm is predictive of poor
neurological recovery. Basilar invagination, also known as vertical subluxation is defined as
27
extension of the odontoid tip more than 4.5mm above McGregor’s line although erosion of the
odontoid may make this difficult to apply. Basilar invagination occurs in 20% and is not always
associated with atlanto-axial subluxation. 5mm or more of cranial settling has been considered the
watershed for operative intervention Radiographic progression often does not coincide with
neurologic progression and peripheral disease can mask neurological sign and symptoms. CT
myelography with multiplanar reconstruction is reliable to evaluate cervical cord compression but
does not demonstrate intracordal changes. MR will provide good visualisation of the pannus
formation, the degree of cord compression, the componenets of that compression and intrinsic cord
changes. The detail of the bone changes is not so well demonstrated on MR. The normal diameter
of the cord at C2 is 9mm and a cord diameter below 6mm on flexion has been reported to be at risk
of neurological deficit while a cervico-medullary angle below 1350 also has a strong correlation
with myelopathy due to vertical subluxation of the odontoid peg. Sub axial subluxation defined as
greater than 3.5mm of translation is due to the facet joint destruction, ligament laxity and
intervertebral disc degeneration and erosion and often produces a step-‘ladder’ deformity. The
normal diameter of the canal from C2 to C7 varies between 14-23mm and 14mm is the minimum
requirement for cord, CSF and dura. Patients with measurements below this level or with significant
mobility should undergo flexion / extension MR studies to evaluate the true space available for the
cord.
Abstract no. 12
MRI OF PERIPHERAL RHEUMATOID ARTRHTITIS - WITH EMPHASIS ON ASSESSMENT
OF INFLAMMATION
Mikkel Østergaard, MD, PhD, DMSc
Depts.of Rheumatology, Copenhagen University Hospitals at Herlev, Hvidovre and Rigshospitalet and The
Danish Research Center of Magnetic Resonance, Copenhagen University Hospital at Hvidovre, Copenhagen,
Denmark
The cornerstones of diagnosis and monitoring of rheumatological diseases are the history and
physical, laboratory and radiographic examinations. However, the soft tissues, which are the site of
primary involvement in most rheumatological disorders, are not or only very poorly visualised by
conventional radiography. Furthermore, in inflammatory joint diseases, the conventional clinical
and laboratory methods are neither very sensitive nor specific, particularly not in the early phases of
the disease.
MRI offers multiplanar imaging with unmatched soft tissue contrast and high spatial resolution.
Synovitis, the primary joint lesion in RA, can be detected and monitored. In contrast, conventional
radiography only shows the late signs of preceding synovitis. A number of other soft tissues of
importance to the integrity and function of the joint may be involved in inflammatory joint diseases.
Soft tissue changes as tenosynovitis, tendonitis, enthesitis, joint effusions and ligament and tendon
tears can all be visualized by MRI.
The majority of studies investigating synovitis have used “conventional “static” Gd-enhanced
MRI”, i.e. application of T1-weighted (T1w) images before and after i.v. injection of a gadoliniumcontaining contrast agent (Gd). At “dynamic” MRI, a series of rapidly repeated images are acquired
at the time of Gd injection, allowing evaluation of the dynamics of the early synovial post-contrast
enhancement. The early synovial enhancement, measured by dynamic MRI, mainly reflects the
synovial vascularity. Dynamic MRI appears to be the most accurate method for assessment the
inflammatory activity of the joint. Another quantitative approach is measuring the volume of
inflamed synovial membrane (the “inflammatory load”) from static MR images. These quantitative
measures have in knee joints been shown to be closely correlated with histopathological findings
and are sensitive to therapy-induced changes. Therapy-induced changes are in knee joints 3-6 times
28
the smallest detectable difference, documenting that the reproducibility of these measures is
sufficient to allow registration of changes in clinically relevant situations.
It is yet to be fully explored, to which extent semiquantitative “scoring” of synovitis, which is
considerably less time-consuming, can replace these quantitative measures, but the available studies
have found a relatively close correlation. Furthermore, a recent study of MCP joints in early and
established RA demonstrated a close correlation between semi-quantitative assessments of synovitis
by mini-arthroscopy and MRI.
Imaging without the use of a contrast agent would decrease examination times, patient discomfort
and costs. The edema of the inflamed synovium can be detected by T2-weighted fat saturated (T2w
FS) images. Fat saturation requires a homogenous magnetic field and a high field strength. The
STIR sequence is an alternative fat-signal elimination technique, which can be used also by lowfield MRI units. T2w FS and STIR images have not been validated against pathological references
and the exact loss of sensitivity compared to Gd-enhanced T1w imaging is not known.
In small studies, it has been attempted to define MRI criteria as an adjunct to the ACR 1987 criteria
for RA and an improved diagnostic accuracy was found. Other small studies have shown that in
RA, MRI signs of inflammation are more frequent in the synovial membrane than at the insertions
of ligaments and tendons (enthesitis), while the opposite is true for seronegative
spondyloarthropathies. Thus, a differential diagnostic value of MRI is suggested, but not definitely
established. Other studies have reported a predictive value of MRI-signs of synovitis with respect to
future erosive progression in established as well as early RA.
In conclusion, MRI offers detailed assessment of all the soft tissues involved in inflammatory joint
diseases. Particularly, synovitis can be detected and monitored with high sensitivy to early
pathology and to change. On top of this, MRI findings are of prognostic value for future erosive
progression in RA. Consequently, MRI must be expected to gain a major role in future trials and in
the clinical management of rheumatoid artritis and other inflammatory joint diseases.
29
th
Friday, 13th June 03.10 – 04.40 p.m. – Seronegative spondyloarthropathy SpA) – Course III
Chair: J. Freyschmidt (D), N. Egund (DK)
Abstract no. 13
SERONEGATIVE SPONDYLOARTHROPATHY (SPA) – CLINICAL ASPECTS
Berit Schiottz-Christensen, MD, PhD
Dept. of Rheumatology, Aarhus University Hospital;aarhus, Denmark
The entity of seronegative spondyloarthropathy (SpA) comprises of ankylosing spondylitis, reactive
arthritis, enteropatic arthritis, psoriatic arthritis and undifferentiated SpA. Since 1974 the New York
criteria has been used to identify patients having ankylosing spondylitis (1). These criteria have
established radiographic evidence of sacroiliitis as the most important factor for the diagnosis of
ankylosing spondylitis. In 1991 the European Spondylathropathy Study Group (ESSG) proposed
new classification criteria (2). The ESSG-critaria includes patients with sacroiliitis as well as
patients with only peripheral joint or enhteseal inflammation. According to the ESSG terminology
spondyloarthritis is defined as the entire spectrum of seronegative, HLA-B27 –positive related
diseases, which is a much more extensive entity than the group of patients classified according to
the New York criteria (Figure 1).
The pathogenesis of SpA is poorly understood. SpA is associated with HLA-B27 and characterised
by inflammatory changes of enthesis (enthesitis), described as inflammation at the insertion of a
tendon, ligament, capsule or fascia into bone (3). Sacroiliitis is the hallmark of the disease.
The incidence of SpA is about 0.5-2.0 % (4). The initial symptoms occur between 20 and 40 years
of age, but typically the time of diagnosis is 5-10 years later, when progressive structural damage
has been recognised or radiographic abnormalities of the sacroiliac joints or spine are apparent (5).
The introduction of MRI in patients having inflammatory low back pain might change time of
diagnosis because inflammation as the preliminary changes in SpA will be visualized by using this
technique (6). The inflammatory changes are not visualized at imaging based on X-rays.
The course of SpA is highly variable and can be characterised by spontaneous remissions and
exacerbations, particularly in the early stages of the disease. The long time outcome is considered to
be favourable according to pain, but recent studies indicate that patients with severe SpA are as
least as disabled as age matched patients with RA.
The aim of the treatment strategy is to relieve symptoms and improve function, but no currently
approved treatment alters the natural course of the disease. Non-steroidal anti-inflammatory drugs
(NSAID) and physiotherapy are currently accepted treatments for reducing the signs and symptoms
of SpA with localized inflammatory back pain and enthesitis (7). DMARD as Salazopyrin and
Metotrexate are used in patients having arthritis. Anti-TNF-α has shown promising effect on the
inflammatory process in the SI-joint, but no long time studies indicating remission are available (8).
The ESSG propose a core set of instruments for each of 10 domains (Figure 2) selected to evaluate
disease-controlling treatment (9). Most of the instruments are validated and clinicians are invited to
use the instruments to monitor diagnostic procedures as well as medical treatment, physical therapy
and other interventions done to optimise daily living among patients having SpA. If the core set is
used in the clinic, valuable information will be available in the future.
References
1. van der LS, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A
proposal for modification of the New York criteria. Arthritis Rheum 1984; 27(4):361-368.
30
2. Dougados M, van der LS, Juhlin R, Huitfeldt B, Amor B, Calin A et al. The European
Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy.
Arthritis Rheum 1991; 34(10):1218-1227.
3. Francois RJ, Braun J, Khan MA. Entheses and enthesitis: a histopathologic review and relevance to
spondyloarthritides. Curr Opin Rheumatol 2001; 13(4):255-264.
4. Braun J, Bollow M, Remlinger G, Eggens U, Rudwaleit M, Distler A et al. Prevalence of
spondylarthropathies in HLA-B27 positive and negative blood donors. Arthritis Rheum 1998; 41(1):5867.
5. Feldtkeller E, Bruckel J, Khan MA. Scientific contributions of ankylosing spondylitis patient advocacy
groups. Curr Opin Rheumatol 2000; 12(4):239-247.
6. Oostveen J, Prevo R, den Boer J, van de LM. Early detection of sacroiliitis on magnetic resonance
imaging and subsequent development of sacroiliitis on plain radiography. A prospective, longitudinal
study. J Rheumatol 1999; 26(9):1953-1958.
7. Dougados M, Behier JM, Jolchine I, Calin A, Van Der HD, Olivieri I et al. Efficacy of celecoxib, a
cyclooxygenase 2-specific inhibitor, in the treatment of ankylosing spondylitis: a six-week controlled
study with comparison against placebo and against a conventional nonsteroidal antiinflammatory drug.
Arthritis Rheum 2001; 44(1):180-185.
8. Braun J, Brandt J, Listing J, Zink A, Alten R, Golder W et al. Treatment of active ankylosing spondylitis
with infliximab: a randomised controlled multicentre trial. Lancet 2002; 359(9313):1187-1193.
9. Braun J, Golder W, Bollow M, Sieper J, van der HD. Imaging and scoring in ankylosing spondylitis.
Clin Exp Rheumatol 2002; 20(6 Suppl 28):S178-S184.
Figure 1. Diagnostic criteria
The New York criteria (1974):
European Spondylarthropathy Group (ESSG) criteria (1991):
Sacroiliitis, grade ≥ II bilaterally or grade III to
IV unilaterally
Low back pain and stiffness for more than 3
months that improves with exercise but is not
relieved by rest
Limitation of motion of the lumbar spine in both
the sagital and frontal planes
Limitation of chest-expansion relative to normal
values correlated for age and sex.
Inflammatory spinal back pain
OR
Synovitis (asymmetric, predominantly in the lower extremities)
AND (at least one of the following)
Alternating buttock pain
Sacroiliitis
Heal pain (enthesitis)
Positive family history
Psoriasis
IBD (Chron´s disease, ulcerative colitis)
Urethritis/acute diarrhoea in preceding 4 weeks
Figure 2. Core set for domains for the evaluation of Ankylosing Sondylitis
Domain
Instrument
Function
Pain
Spinal mobility
Patient global
Stiffness
Peripheral joints and enthesis
Acute phase reactants
Radiograph spine and hips
Fatigue
BASFI (functional index)
VAS, past week, spine, at night, due to AS and VAS past week, spine, due to AS
Chest expansion and modified Shober and occiput-to-wall distance
VAS past week
Duration of morning stiffness, spine, past week
Number of swollen joints and enthesis
ESR
AP - lateral lumbar and cervical spine, and pelvis (SI and hips)
Currently no preferred instruments
31
Abstract no. 14
IMAGING OF THE SACROILIAC JOINT AND SACROILIITIS
N. Egund, MD
Dept. of Radiology R, Aarhus University Hospital, Aarhus, Denmark
Introduction
Seronegative inflammatory disorders of the sacroiliac joint, spondylarthropaties (SpA) are
according to the European Spondylartropathy Study Group (ESSG) separated into five entities: 1.
reactive arthritis, 2. psoriasis arthritis, 3. ankylosing spondylitis, 4. arthritis associated with
inflammatory bowel diseases and 5. unclassified SpA. Involvement of the sacroiliac joint in
rheumatoid arthritis appears less clarified.
Arthritis in the peripheral joints is associated with synovitis and commonly followed by bony
erosions at the junction between cartilage and synovia as visualized at radiography, ultrasound and
MR imaging. The type of abnormalities and lesions of inflammatory disorders of the sacroiliac joint
as demonstrated at imaging, has little in common with those of arthritis in the synovial joints, but
similarities with the lesions at SpA occurring in the symphysis and the discovertebral junction of
the spine.
Therefore, how is the anatomy of the sacroiliac joint composed?
Anatomy and histology of the sacroiliac joint
The sacroiliac joint is composed of a C-shaped cartilaginous articulation (Fig. 1 and CJ in Fig.2)
between the iliac and sacral bone (Fig. 2) and a dorsal syndesmosis (DJ in Fig. 2) in which the
adjacent bony surfaces are united by interosseous ligaments. At histology, the cartilaginous
articulation has the characteristics of a symphysis in which surrounding ligaments are attached to
the hyaline cartilage in a zone of fibrocartilage (Fig. 3). This is true except in the distal 1/3 of the
joint where the ventral and dorsal transition (VT and DT in Fig 2) of the iliac bone resemble some
characteristics of a synovial articulation (Fig. 4).
Fig. 1
Fig. 2
Fig. 3
Normal variants at MR imaging
The dorsal transition between the cartilaginous articulation and the syndesmosis may at MR
imaging within the proximal portion of the distal 1/3 of the joint demonstrate a number of
32
anatomical variants (Fig. 5), which can simulate signs of erosions, inflammation and also
stressfractures.
Fig. 4
Fig. 5
Techniques of imaging
Radiography: 200 AP view only. Bilateral oblique views do not contribute to additional diagnostic
information. The radiation dose of two oblique views may surpass that of coronal CT imaging.
Radiographic signs of sacroiliitis may be demonstrated one to two years later than MR imaging.
CT: Considering radiation protection purposes, CT should only be performed in the oblique coronal
plane (Fig. 1). At CT, signs of sacroiliitis are subchondral bone sclerosis, erosions and
enthesophaties of the syndesmosis.
Ultrasound: Considering the anatomy of the joint and the site of the most common abnormalities,
there is no rationale for this procedure or additional interventions.
MR imaging: Oblique transaxial (Fig. 1) STIR or T2 fat saturated sequences will visualize any
active inflammation of the sacroiliac joint and the anatomical site of lesions. Oblique coronal T1
imaging visualizes bone sclerosis, erosions in the cartilaginous joint and subsequent bone marrow
conversions. Gadolinium contrast studies in the oblique transaxial plane may further enhance the
information about activity of joint disease.
Differentiation between types of sacroiliitis at MR imaging
The talk will include attempts at MR imaging to differentiate between the five (six) types of SpA.
Abstract no. 15
THE SPINE: IMAGING OF DIFFERENT FORMS OF SPONDYLOARTHROPATHIES
V. Jevtic, M.D.,
Clinical Radiology Inst., University Clinical Centre Zaloska 7, SI – 1525 Ljubljana, Slovenia
33
Seronegative spondyloarthropathies (SNSA) represent an important group of heterogenous
inflammatory rheumatic diseases. In contrast to rheumatoid arthritis (RA) an absence of rheumatoid
factor in the serum is characteristic, hence the term “seronegative”. Oftenly the SIJ and the joints of
the spine are affected, which is the reason for the name “spondyloarthritis”.
SNSA include several rheumatic diseases: ankylosing spondylitis (AS), psoriatic arthritis (PA),
reactive arthritis and Reiter’s syndrome (RS), enteropathic arthritis (Chron’s disesase, ulcerative
colitis), juvenile chronic arthritis and undifferentiated spondyloarthritis. The diseases share many
common clinical features – in practice, the most important include the presence of inflammatory
back pain and significant prevalence of HLA – B 27 antigen.
There are several unifying pathoanatomic features characteristic of SNSA (which are also the main
differential diagnostic criteria to RA). Concerning the affection of the axial skeleton the most
important are as follows:
1. There is predilection for fibrocartilaginous articulations, such as the discoverebral junction and
and the iliac side of the SIJ.
2. Histologicaly enthuses - the insertions of ligaments, tendons and articular capsules are also
fibrocartilaginous structures (there is a zone of cartilage interposed between the tendon and the
bone). Enthesitis - an inflammatory enthesopathy - is the hallmark of SNSA, and is often seen as
one of the first radiological manifestation of the disease. Enthesitis is frequently localised at the
insertions of ligaments around the intervertebral disc and the sacroiliac joints.
3. An important diagnostic feature of SNSA is simultaneous exsistence of all reactive joint – bone
capabilities. From the begining of the disease there may be a combination of destructive and
productive changes (demineralization, erosions-periostosis, osteosclerosis, ankylosis). This is an
important difference to bacterial and rheumatoid arthritis in which these phases appear
successively!
During the course of different SNSA, a variety of changes affect the discovertebral junctions the
apophyseal and the costoverebral joints, the occipitoatlantal and atlantoaxial articulations and the
paravertebral ligaments. Mb. Bechterew spondylitis usually begins at the thoracolumbar and
lumbosacral junctions. The initial pathoanatomic change is an enthesitis at the insertion of the
annulus fibrosus-longitudinal ligament complex (Sharpey’s outher fibers of the annulus fibrosus)
termed Romanus lesion, spondylitis anterior or marginalis. The earliest phase is characterised by
ingrowth of edematous, hyperemic inflammatory tissue and bone destruction at the margins of
vertebral bodies. Radiologically, discrete focal erosions appear at the vertebral body corners along
the anterior, lateral and posterior surfaces of the neighbouring segments. Initial erosion is localised
several mm away of the vertebral rim at the insertion of annulus fibrosus. These discrete erosions
are an early and significant sign of AS. When searching for early spondylitis the initial diagnostic
step can be cone down lateral view of the T-L or L-S junction. Gd-DTPA MRI is a sensitive
indicator of early rheumatic inflammatory changes and may be used as the first diagnostic step or
the next if radiography is negative. MRI closely reflects histopathological changes and can
demonstrate an early Romanus lesion without bone destruction. Low signal intensity areas in the
region of the anterior annulus fibrosus on T1W SE precontrast image with marked contrast
enhancement long annulus fibrosus, and the neighbouring vertebral body margins on T1W
postcontrast image represent an enthesitis and are compatible with edematous, hyperemic
inflammatory tissue, which has been proved in histological specimens of patients with early AS.
The exact pathogenesis of discovertebral destruction in AS is not completely clear. Using GdDTPA MRI we were able to demonstrate gradual extension of spondylitis marginalis into the
intevertebral disc. The initial Romanus lesion and the advanced inflammatory destructive so-called
Andersson’s lesion represent different evolutionary stages of the same continous inflammatory
process. Spondylitis marginalis seems to precede to inflammatory Andersson's lesions.
Early focal destructive lesions progress, and later on affect also the vertebral rim - previous
epiphyseal ring. The vertebral body corner looks as being planed down. One of the typical features
of AS are so-called “square vertebras”, which indicates loss of normal concavity of the vertebral
34
body. It reflects periosteal apposition along the anterior and the posterior surfaces causing filling-in
of the normal concave vertebral body contour. The second cause of squaring phenomenon is already
mentioned destruction of vertebral body corners. If pronounced, these two processes may produce
convexity of the anterior surface of the vertebral body known as “barrel-shaped” vertebra. Similarly
to rheumatic SI early erosions are followed by perifocal reactive new bone production, which
creates sclerosis and “whitening” of vertebral body corners or “shiny corner” appearance on
radiography. These productive changes appear as a part of healing of destructive lesions.
Marginal erosions are followed by metaplastic ossification of the outher Sharpey’s fibers of the
annulus fibrosus. Reparative ossification extends longitudinally and finally connects the
neighbouring vertebral body corners. These peripheral bony connections typical for AS are termed
syndesmophytes. Typical syndesmophytes are delicate bone outgrowths, which connect adjacent
vertebral bodies in vertical direction. In advanced AS marginal syndesmophytes are symmetric and
numerous. In the late stage of the disease widespread syndesmophytes produce the picture of
“bamboo spine” and complete ankylosis of the vertebral column. It is of practical importance to
differentiate syndesmophytes from parasyndesmophytes (or nonmarginal syndesmophytes), which
are typical for PA and RS. They result from mataplastic ossification within the prediscal space
between the annulus fibrosus and the anterior longitudinal ligament. Therefore parasyndesmophytes
also extend vertically but connect the vertebral bodies several mm away of their margins. Contrary
to syndesmophytes they are robust, sparse and asymmetric. Differentation between various bony
outhgrowths of the spine is of considerable clinical importance. The picture of “bamboo spine” with
typical symmetric, generalised syndesmophytes is diagnostic of AS. On the other hand the
appearance of parasyndesmophytes, which are robust, sparce and asymmetric is diagnostic of PA
and RS. Unfortunately, different outhgrowths often combine, especially in older patients.
Occasionally parasyndesmophytes are also seen in AS. A quater of patients with PA and RS have
syndesmophytes.
A late manifestation of AS are advanced destructive discovertebral lesions. According to Dihlmann
there are two types of these, type A inflammatory and type B noninflammatory Andersson's lesions.
This classification is of clinical significance since in noninflammatory Andersson's lesions, which
represent pseudoarthrosis spinal stabilization may be indicated. Inflammatory Andersson's lesions
appear within nine years after the begining of AS. Usually several intervertebral discs are affected.
Paucity or absence of syndesmophytes is also characteristic. The lesions were originally described
as multiple defects of the vertebral body endplates surrounded by broad perifocal sclerosis with
narrowing of the disc spaces. Non-inflammatory Andersson's lesions are seen ten or more years
after the begining of AS. The lesion represents pseudoarthrosis due to trauma or stress to the
ankylosed spine. Typically, ankylosed spine with numerous syndesmophytes is demonstrated. As a
rule only one intervertebral disc is affected, usually at the level of the T-L junction. It may be
widened or narrowed the endplates are eroded surrounded by bone sclerosis.
Abstract no. 16
PUSTULOTIC ARTHRO-OSTEITIS/SAPHO SYNDROME
Anne Grethe Jurik
Dept. of Radiology R, Aarhus University Hospital, Noerrebrogade 44, DK 8000 Aarhus C
Pustulotic arthro-osteitis (PAO) is an osteo-arthropathy associated with the dermal disease
pustulosis palmoplantaris. It has generally been accepted that PAO belong to the group of
seronegative spondylarthropathies (SpA). According to the classification of the European
Spondyloarthropathy Study Group (ESSG) in 1991 [1] SpA comprises ankylosing spondylitis,
psoriatic and reactive arthritis, arthritis associated with inflammatory bowel disorders and
35
unclassifiable SpA. By the classification of PAO as a form of SpA the group of unclassifiable SpA
disorders has decreased since 1991.
PAO has similarities with the other forms of SpA, but is also somewhat different due to a tendency
to produce more osseous sclerosis than generally seen in the other forms of SpA. This has caused
PAO sometimes to be included under the term SAPHO-syndrome (synovitis, acne, pustulosis,
hyperostosis, osteitis) [2;3]. SAPHO-syndrome has been described to encompass inflammatory
hyperostotic bone lesions occurring together with skin eruptions, including PAO in addition to
multifocal osteomyelitis and acne osteo-arthropathy. Acne-associated skeletal changes are however
different from those associated with PPP, and the hyperostosis is usually a result of chronic aseptic
osteitis. Grouping of all these peculiar disorders under one name is inappropriate. Disease entities
are always best described by a name that directly reflects their cardinal pathologic features,
especially if they are to be evaluated further with regard to aetiology and pathogenesis. The
pathogenesis of PAO is probably an autoimmune reaction, an atypical immune response to viral or
bacterial antigens or a jet not detected organism. The finding of a possible genetic translocation in
multifocal osteomyelitis [4] has stimulated research within aetiology and pathogenesis, which
demand a strict classification in separate disease entities. Radiology has an important role in such
research as the imaging features sometimes allow differentiation between the disorders, and MRI is
important as a guide to adequate biopsy.
The presentation will concentrate on the radiological features of PAO.
Location of PAO lesions:
PAO is like other forms of SpA often located to the spine, but PAO is more frequently located to
the anterior chest wall (ACW) than the other forms of SpA. Besides, sacroiliac and peripheral joint
involvement is rare in PAO whereas peripheral bones may be involved.
Radiography/CT:
Involvement of the anterior chest wall (ACW) characteristically consist of hyperostotic and
sclerotic changes in the sterno-costo-clavicular region, mainly involving the bones, but also the
cartilages and ligaments (Fig. 1)[5-7]. Due to the phenomenon of overprojection in the ACW region
supplementary CT or MRI is often needed to characterize the changes. The osseous, cartilaginous
and ligamentous changes are usually best demonstrated by CT (Fig. 1).
Spinal lesions are typically characterised by osseous vertebral sclerosis accompanied by erosion of
vertebral endplates (Fig. 2). Accompanying syndesmophytes may occur like in other forms of SpA
(Fig. 2)[5].
Sacroiliitis is not a typical feature of PAO, but can occur, and sclerotic osseous PAO lesions may be
located adjacent to the sacroiliac joint [5;7].
Involvement of peripheral bones can occur, mostly in the form of osteitis or ossifying periostitis, in
some cases mimicking malignancy. Also enthesitis and calcifying tendonitis may be seen, but
peripheral arthritis is rare and usually non-erosive [5;7].
MRI:
Reports of the value of MRI in PAO are only casuistically. MRI may add information with regard to
disease activity and extend in all regions (Fig. 3). It may disclose soft tissue inflammation anterior
to spondylitis changes, and exclude changes suggesting infectious lesions. As fatty degeneration in
the bone marrow often occur in long lasting PAO lesions it is important to include fat suppressed
MR sequences.
Scintigraphy:
Scintigraphy may reveal a characteristic "bullhead sign" corresponding to ACW involvement in
PAO, and also involvement in other skeletal areas such as the spine, sacroiliac joint and peripheral
bones/joints [8;9].
36
Conclusion:
PAO is a relative rare disorder associated with the dermal disease pustulosis palmoplantaris (PPP)
and belonging to the group of seronegative spondylarthropathies (SpA). PAO is like other forms of
SpA often located to the spine, but PAO is more frequently located to the anterior chest wall than
the other forms of SpA. Besides, sacroiliac and peripheral joint involvement is rare in PAO whereas
peripheral bones may be involved. PAO is radiographically generally characterised by more
osseous sclerosis and hyperostosis than seen in other forms of SpA. The lesions may simulate
malignancies so it is important to be aware of the disorder to avoid unnecessary diagnostic
procedures. If PAO is suspected, look for dermal manifestations of PPP.
References
1. Dougados M, van der Linden S, Juhlin R, Huitfeldt B, Amor B, Calin A, Cats A, Dijkmans B, Olivieri I,
Pasero G (1991) The European Spondylarthropathy Study Group preliminary criteria for the
classification of spondylarthropathy. Arthritis Rheum 34: 1218-1227
2. Kahn MF, Chamot AM (1992) SAPHO syndrome. Rheum Dis Clin North Am 18: 225-246
3. Toussirot E, Dupond JL, Wendling D (1997) Spondylodiscitis in SAPHO syndrome. A series of eight
cases. Ann Rheum Dis 56: 52-58
4. Golla A, Jansson A, Ramser J, Hellebrand H, Zahn R, Meitinger T, Belohradsky BH, Meindl A (2002)
Chronic recurrent multifocal osteomyelitis (CRMO): evidence for a susceptibility gene located on
chromosome 18q21.3-18q22. Eur J Hum Genet 10: 217-221
5. Jurik AG, Helmig O, Graudal H (1988) Skeletal disease, arthro-osteitis, in adult patients with pustulosis
palmoplantaris. Scand J Rheumatol Suppl 70: 3-15
6. Jurik AG (1990) Anterior chest wall involvement in patients with pustulosis palmoplantaris. Skeletal
Radiol 19: 271-277
7. Kasperczyk A, Freyschmidt J (1994) Pustulotic arthroosteitis: spectrum of bone lesions with
palmoplantar pustulosis. Radiology 191: 207-211
8. Freyschmidt J, Sternberg A (1998) The bullhead sign: scintigraphic pattern of sternocostoclavicular
hyperostosis and pustulotic arthroosteitis. Eur Radiol 8: 807-812
9. Dihlmann W, Dihlmann SW, Hering L (1997) Acquired hyperostosis syndrome - AHYS (sternocostoclavicular hyperostosis, pustulotic arthro-osteitis, SAPHO-syndrome): bone scintigraphy of
the anterior chest wall. Clin Rheumatol 16: 13-24
37
Figures
a
b
c
Fig. 1. ACW involvement. (a) Oblique projections of the sternoclavicular joint showing osseous
sclerosis and erosion of the sternal joint facets. (b) Transverse CT slices and (c) coronal 2D
reconstruction reveal erosion of the sternal and clavicular joint facets with pronounced osseous
sclerosis in the upper part of the sternum. There is concomitant involvement of the upper anterior
ribs/cartilages and costoclavicular ligament resulting in an ossified ACW plate.
38
a
b
c
Fig. 2. Spinal involvement/CT. (a) AP and lateral radiograph showing sclerosis of the 9th thoracic
vertebra, (b) Transverse CT slices and (c) coronal + sagittal 2D reconstruction reveal diffuse
sclerosis of the vertebral body and the lower corner of the adjacent vertebra. In addition, erosion of
the vertebral endplates and sclerotic syndesmophytes.
a
b: STIR
T1
T2
Fig. 3. Spinal involvement/MRI.
(a) AP and lateral radiograph showing sclerosis of the 5th lumbar vertebra. (b) Sagittal STIR, T1 and
T2 weighted images. The diffuse bone marrow oedema in L5 is most clearly visible at the STIR
sequence.
39
th
Saturday, 14th June 08.00 –09.20 a.m. – Childhood disorders (RA) – Course IV
Chair: K. Johnson (UK), M. Zanetti (CH)
CLINICAL ASPECTS
T. Herlin
Dept. of Paediatrics A, Aarhus University Hospital, Skejby, Aarhus, Denmark
Abstract no. 18
IMAGING OF JUVENILE CHRONIC ARTHRITIS; SYSTEMIC, PERIPHERAL AND AXIAL
ARTHRITIS
Dr. Karl Johnson
Birmingham Children’s Hospital, U.K.
Juvenile Idiopathic Arthritis (JIA) is an inflammatory disorder of childhood that may affect any
joint and involve any organ system. The disease is relatively common with an incidence of 5-18 per
100,000 children, similar to that of childhood diabetes. If there is a delay in diagnosis and treatment
JIA can result in severe damage to the joints with significant loss of function. In children
uncontrollable disease can result in loss of schooling and reduced employment prospects.
The term Juvenile Idiopathic Arthritis has only recently been introduced (1999). In North America
the term Juvenile Chronic Arthritis (JCA) was used, whilst in Europe the term Juvenile Rheumatoid
Arthritis (JRA) was adopted. Both these terms described the same disease process and therefore
there was some confusion between the various sub-groups of the disease. The term JIA even though
not changing the underlying pathological process helps to unify all the disorders under one title with
various sub-headings. This aids diagnosis, clinical follow-up, research and management.
JIA is defined as a chronic arthritis that develops before the 16th birthday persisting for more than 6
weeks with the exclusion of other causes. Even though the diagnosis is a clinical one; radiology
plays a vital role in excluding other causes of joint pain, confirming the diagnosis, monitoring the
effects of treatment and in the long-term follow-up of patients.
The earliest radiological features of disease are soft tissue swelling around the joints, periarticular
osteoporosis and metaphyseal widening. These all are the result of the hyperaemia associated with
the underlying disease process. This hyperaemia will cause localised growth disturbance causing
limb length discrepancy and bone remodelling. If the disease remains untreated and progresses there
will be loss of articular cartilage leading to joint space narrowing, bone erosions and in severe cases
there may be bony ankylosis with significant reduction in movement and function.
MRI is ideally suited to study JIA as it allows visualisation of the joint multiple planes. The
selection of specific sequences allows identification of marrow oedema, soft tissue changes and
cartilage damage. The use of post-gadolinium T1 weighted fat-suppressed sequences is the
optimum sequence to visualise the inflamed synovium. Ultrasound has been shown to be very
useful in adults in detecting effusions and synovial hypertrophy. Its use in children has been
40
somewhat limited. On ultrasound the synovium is of relatively mixed echogenicity, with an
irregular outline and there is usually an associated hypoechoic effusion. The synovium is shown to
be relatively hypervascular on power Doppler imaging.
The differential diagnosis of JIA includes any disorder that can result in restricted function, joint
swelling and pain. In the younger child the important differentials are metastatic neuroblastoma and
leukaemia. In all age groups infection, primary bone tumours, skeletal dysplasia and metabolic
conditions need to be excluded.
There have been major advances in therapeutic options to management of JIA. It is important that
the diagnosis is arrived at as early as possible so that treatment can be optimised and the child
maintain as normal function and mobility as possible.
References
•
•
•
Petty RE et al. Revision of the proposed classification criteria for juvenile idiopathic arthritis
Rheumatol 1998; 25; 1991-1994.
Ansell B, Kent PA. Radiological changes in juvenile chronic polyarthritis.
Skeletal Radiol 1977;1:129-144
Johnson K and Gardiner-Medwin. Juvenile arthritis: Classification and Radiology
Clinical Radiol 2002; 57: 47-58
Abstract no. 19
HEMOPHILIA, PLAIN RADIOGRAPHY AND MRI
Holger Pettersson
Lund, Sweden
The most common clinical manifestation of hemophilia is repeated joint bleedings that lead to
hemophilic arthropathy. In the natural course of the disease, this arthropathy will totally disable the
patient in his teens. The hemophilic arthropathy involves hemosiderin deposition, synovial
inflammation, hypertrophy and fibrosis, cartilagineous destruction, periarticular degeneration, and
bone destruction that in the end will lead to total joint derangement.
Plain Radiography
Before the MR era, and also today in the majority part of the world, the progression of joint
destruction can be monitored using conventional X-ray. The radiograph gives information on the
progressive joint destruction, although the soft tissue and cartilagenous changes can be visualized to
a quite limited degree. Thus, initial bleedings may be seen as a distension of the joint, and after
repeated bleeding with deposition of hemosiderosin and development of synovial hypertrophy, this
is visible as an increased density in the periarticular soft tissues. Secondary to the hyperemia caused
by the bleedings, there is periarticular osteopenia, and in childhood also an accelerated ossification
and growth of the epiphyses.
Progressive degeneration of the cartilage results in joint space narrowing and subchondral bone
irregularity. Erosions and subchondral cysts appear as the degeneration progresses. The
combination of osteopenia and cyst formation may cause subchondral collapse with loss of
congruity of the joint surfaces, resulting in displacement and angulation of the bone ends.
Subchondral sclerosis may be noted. In the natural course (if adequate treatment is not available),
the end-result of the arthropathy is a totally destroyed joint, or possibly bony anchylosis.
41
From this description, it is clear that important early changes, including soft tissue pathology, joint
effusion and cartilagenous destruction, cannot be directly studied using X-ray. But given modern
treatment, with factor replacement on demand or as prophylaxis, it has been increasingly important
to evaluate these early changes in order to monitor treatment and to evaluate new treatment
regimens.
MRI
Today, with the excellent ability to define soft tissue pathology with MRI, most abnormalities
appearing in the joint space, the synovium, cartilage, and periarticular tissues, as well as those in the
bone, can be followed in great detail. Fresh blood in an acute bleeding is easily detectable, but
because of varying signal characteristics of resolving hemorrhage, it may be difficult to distinguish
between joint fluid and blood in a hemophilic joint. The presence of hypertrophic synovial tissue is
clearly detected using T1- and T2-weighted images, but after repeated hemarthroses, a mixture of
low and high signal intensity may be seen caused by the coinciding presence of synovial
hypertrophy, fibrosis and hemosiderin deposition. In such cases, the use of intravenous gadoliniumbased contrast media will facilitate the definition of the synovial hypertrophy. Using sequences
aimed at examination of the cartilage, early detection of joint cartilage changes is possible, as well
as the later ongoing destruction. Bone destruction is likewise imaged by MRI, as are the
subchondral cyst formations. Secondary lesions of the periarticular structures are well defined.
In order to quantify the degree of joint destruction, several classification methods using X-ray have
been suggested in the past. Since about 20 years, the World Federation of Hemophilia has
recommended a classification in which involved joints may be given a score ranging between 0 and
13. This score has been widely used for scientific purposes and for evaluation of different treatment
regimens.
However, for the morphologic evaluation of the extent of the synovial tissue, as well as the
cartilage, MR-based scores for classification have been suggested including not only the chondral
destruction, subchondral cysts and destruction of the subchondral cortex, but also of hemarthrosis,
synovial hypertrophy, and hemosiderin deposition. These classification scores are still being
evaluated, and under the auspices of the World Federation of Hemophilia, a general MR score is
hopefully presented as suggested for worldwide use by the end of this year.
42
th
Saturday, 14th June, 09.20 – 10.10 a.m. – Crystal induced and related disorders - Course V
Chair: K. Johnson (UK), M. Zanetti (CH)
GOUT AND HYDROXYAPPATITE ARTHRITIS
M. Cobby
Dept. of Clinical Radiology, Bristol Royal Infirmary, UK
Abstract no. 21
PSEUDOGOUT AND RELATED DISORDERS
Marco Zanetti, M.D.
Dept. of Radiology, Orthopedic University Hospital Zurich, Switzerland
TERMINOLOGY
Various names are used for CPPD crystal deposition disease [1].
Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease: characterized by the presence
of Ca2P2O7 * 2H2O (calcium pyrophosphate dihydrate or CPPD) crystals in or around joints.
Pseudogout: The clinical pattern characterized by intermittent acute attacks of arthritis and
simulates gout.
Chondrocalcinosis: Pathological or radiological evidence of cartilage calcification.
Articular and periarticular calcification: Pathologically or radiological evidence of calcification in
and around articulations.
Pyrophosphate arthropathy: A peculiar pattern of structural joint damage simulating degenerative
joint disease but characterized by distinctive features.
CLINICAL FINDINGS
CPPD crystal deposition disease is observed in middle-aged and elderly patients.
In 10 to 20% the disease is characterized by acute or subacute self-limited attacks of arthritis.
Pseudo-osteoarthritis is the most common affection of CPPD crystal deposition disease (35 -60%).
Pseudo-osteoarthritis is characterized by chronic progressive arthritis with or without acute
exacerbations.
A less common clinical pattern in CPPD crystal deposition disease simulates neuropathic
osteoarthropathy.
Rarely, CPPD crystal deposition disease demonstrates a miscellaneous pattern that suggests
rheumatic fever, psychogenic disease, and trauma.
CPPD crystal deposition disease may be also encountered in asymptomatic joints.
43
DISEASES ASSOCIATED WITH CPPD CRYSTAL DEPOSITION DISEASE
The following diseases have been reported in association with CPPD crystal deposition disease and
should be considered when CPPD is detected:
Diabetes Mellitus
Degenerative Joint Disease
Gout and Hyperuricemia
Hyperparathyroidism
Hemochromatosis
Wilson's Disease
Neuropathic Osteoarthropathy
Ochronosis
Hypophosphatasia
Hypomagnesemia
PATHOGENESIS OF CRYSTAL DEPOSITION AND SYNOVITIS
CPPD
There are two main theories:
One theory favors that deposition of CPPD crystal deposition is an initial step, followed by cartilage
degeneration. In recent years, increasing emphasis has been placed on local tissue damage as a
cause of crystal deposition.
Synovitis
The pathogenesis of acute synovitis in this disease may relate to a process of crystal shedding, in
which cartilaginous deposits are cast into the articular cavity. The process may be accentuated by
joint lavage with crystal solubilizers. Crystal shedding also might be exaggerated in conditions
associated with significant cartilage destruction, such as infection and neuropathic osteoarthropathy.
RADIOLOGIC FEATURES
CPPD crystal deposition disease is associated with calcification of articular and periarticular
structures.
Articular and periarticular calcific deposits may be located in cartilage, synovium, capsule, tendons,
bursae, ligaments, soft tissues, and vessels and may demonstrate some degree of symmetry from
one side to the other.
Chondrocalcinosis may involve fibrocartilage or hyaline cartilage
Fibrocartilaginous calcification is most common in the menisci of the knee, triangular cartilage of
the wrist, symphysis pubis, anulus fibrosus of the intervertebral disc, and acetabular and glenoid
labra, although it may be observed at other sites, such as within the discs of the acromioclavicular
and sternoclavicular joints. Fibrocartilaginous deposits appear as thick, shaggy, irregular radiodense
areas, particularly within the central aspect of the joint cavity.
Hyaline cartilage calcification may occur in many locations but is most common in the wrist, knee,
elbow, and hip. These deposits are thin and linear and are parallel to and separated from the
subjacent subchondral bone.
Synovial Calcification.
Calcification within the synovial membrane is a common feature of CPPD crystal deposition
disease. Synovial deposits are most frequent in the wrist, particularly about the radiocarpal and
distal radioulnar joints, knee, and metacarpophalangeal and metatarsophalangeal joints, but they
also are noted in the glenohumeral, elbow, hip, and acromioclavicular articulations. The deposits
are cloudlike.
Capsular Calcification.
CPPD crystal deposition in joint capsules is observed most commonly in the elbow and
metatarsophalangeal joints but also is observed in the metacarpophalangeal and glenohumeral
joints. These collections appear as fine or irregular linear calcifications that span the joint.
44
Tendinous and ligamentous calcification.
Common locations are the Achilles, triceps, quadriceps, gastrocnemius, and supraspinatus tendons.
Other locations of these calcifications are the ischial and trochanteric regions. In tendons,
calcifications appear thin and linear and may extend for considerable distances from the osseous
margin.
Soft Tissue and Vascular Calcification.
In some patients, poorly defined calcific deposits are seen within the soft tissues and vessels.
Tumorous calcific collections, resembling gouty tophi, occasionally are observed, especially in the
digits.
Pyrophosphate Arthropathy.
Unusual articular distribution is a typical feature: Isolated or significant involvement of the
radiocarpal or trapezioscaphoid joints of the wrist, patellofemoral compartment of the knee, and
talocalcaneonavicular joint of the midfoot may signify CPPD crystal deposition disease.
Prominent subchondral cyst formation may be indicative for CPPD. The cysts associated with
pyrophosphate arthropathy are very numerous and may reach considerable size. Pyrophosphate
arthropathy may be associated with extensive and rapid subchondral bone collapse and
fragmentation, and the appearance of single or multiple intra-articular osseous bodies.
CPPD ON MR IMAGES
Although calcifications are typically of low signal on all MR imaging pulse sequences, high-signalintensity calcium deposits in various anatomical regions have been reported. No single theory has
satisfactorily explained the cause of high signal intensity related to calcifications on certain MR
imaging sequences. CPPD may produce a confounding effect on the MR imaging diagnosis of
meniscal tear. Correlation of MR images with radiography avoids errors in diagnosing meniscal
tears [2].
References
1. Resnick D, Niwayama G. Calcium Pyrophosphate Dihydrate (CPPD) Crystal Deposition Disease. In:
Resnick D, ed. Diagnosis of Bone and Joint Disorders. Philadelphia, Pe: Saunders, W.B., 1995:15561614
2. Beltran J, Marty-Delfaut E, Bencardino J, et al. Chondrocalcinosis of the hyaline cartilage of the knee:
MRI manifestations. Skeletal Radiol 1998;27: 369-374
45
th
Saturday, 14th June 10.40 – 12.00 a.m. – Inflammatory disorders in sports medicine – Course VI
Chair: C. Faletti (IT), N. Egund (DK)
Abstract no. 22
INFLAMMATORY DISORDERS IN SPORTS MEDICINE - POSTTRAUMATIC SYNOVITIS
F. Kainberger1, S. Nehrer²
1
Dept. of Diagnostic Radiology, University of Vienna, Austria
² Dept. of Orthopaedic Surgery, University of Vienna, Austria
Posttraumatic synovitis develops due to hemorrhagic effusions after ruptures or other forceful
damage of the synovium. Main causes are internal derangement of a joint, subluxation or luxation,
capsular disruption, or osseous contusion. Although a well-recognised clinical entity that can be
diagnosed with arthroscopy its importance in the field of diagnostic imaging may have been
underestimated. In a broader sense posttraumatic synovitis is associated with severe forms of minor
or major trauma due to overuse of the joints, bursae, or tendon sheaths.
In the acute phase synovial damage manifests as circumscribed clefts and haemorrhage at the site of
trauma. In the knee, typical submucosal hematoma on the anteromedial part of the joint capsule, on
the medial retinaculum, or in close proximity of the anterior cruciate ligament can be found. In the
chronic phase abnormalities are more generalised in the form of fibrous adhesions especially in
bursae and recessus.
Investigation techniques mainly rely on MRI and in some cases on high-resolution ultrasound. With
contrast media enhancement the extent of synovitis may be recognised to better advantage. Typical
imaging findings include effusion and swelling of the synovium. The latter has been described as a
thin line of increased signal intensity on intermediate weighted images, as frond-like proliferation or
as prominent thickening of the synovium. Rarely, inflammatory pseudotumors may be observed
with or without erosive destruciton of the adjacent bones.
Special forms of posttraumatic synovitis are soft-tissue impingement, plica syndrome, and diffuse
and localized (i.e., cyclops lesion) arthrofibrosis. Various forms of soft-tissue impingement exist in
major and minor joints with impinged synovial folds. The tibiofibular and the patello-femoral joints
are typical locations, other forms of inflammatory synovial plicae may be observed in posterior
impingement of the elbow, the humeroglenoid joint, and minor joints of the spine and the
extremities.
Overuse syndromes may present with signs of inflammation in the form of tendovaginitis, bursitis,
or edema of the fibroosseous channels. They are recognised as part of tendon overuse syndromes
(TOS). Associated inflammation of the tendons may be observed.
The differential diagnosis of posttraumatic synovitis includes seronegative rheumatic diseases and
synovial proliferation due to pigmented villonoduläre synovitis or synovial chondromatosis.
Abstract no.23
TENDINITIS
C. Faletti
Radiology Institute of Sports Medicine, University of Turin, Torino, Italy
46
The term tendinitis derives from Latin and means “inflammation of the tendon”.
Indeed, this term is often used inappropriately and as a rule indicates the presence of tendinopathies.
By tendinitis it is meant the presence of a partial rupture of the collagen fibres, on tendon
degeneration, with loss of collagen continuity at a microvascular level, in association with an
inflammation response.
This, luckily, is rather a rare condition, in particular in a sports context, even if it does occasionally
occur in the Achilles tendon, in the patellar tendon and rotator cuff.
All data in literature acknowledges that the principle cause of tendon pathology is overuse, which
may lead by overloading, by repeated microtrauma, by vascular compromise to tissue reaction of
the tendon structures distinguished in tendinosis, paratenonitis, paratenonitis with tendinosis and
lastly tendinitis.
The most commonly used imaging technique in the study of tendinopathies is U.S. followed by
MRI.
The first examination is that of the U.S. which is able to evidence the tendon structure, both its
components and pathway.
The tendon often has a normal appearance whilst a reaction of the tendon sheath may be observed
whether or not the paratenon is lined by synovium.
The MRI is a highly sensitive examination for this kind of pathology, even if its use is limited.
Sometimes the inflammation of the outer layer of the tendon (paratenon) is associated to tendon
degeneration and in this case, it represents a clinical picture of tendinosis with paratenonitis.
U.S. examination is able to evidence not only the presence of any tendon lesion but also paratenon
tissue lesion as well as MRI.
However, the MRI study offers a panoramic view of the structure and shows the relationship with
the adjacent structures such as muscles, articulation, bones etc.
Tendinosis is the most commonly observed pathology in sports participants.
The U.S. not only evidences the tendon lesion area involved but also allows for a functional study,
which is further enhanced with the use of PW colour doppler, which is able to show also the
vascular structures, in degenerative and repairing phases.
The MRI tends to overestimate the lesion individualizing the mucoid substance, the new
vascularization, the focal necrotic lesions, but does not evidence any presence of calcification.
Therefore, we may conclude by saying that both studies are useful to examine the array of lesions,
included in tendinopathies, the condition of the outer layer and the repairing phase.
Abstract no. 24
IMAGING ENTHESEAL SPORTS INJURY
P J O’Connor, FRCR
Dept. of Radiology, The Leeds Teaching Hospitals Trust, Leeds LS1 3EX, UK
E-mail: Philip.O’[email protected]
Sports Injury is the response of tissue to kinetic energy applied to the body. Damage may occur
locally, or distant from the site of trauma due to transmitted forces, and may be acute or chronic
arising from repetitive strains. The kinetic chain is the functional unit that allows us to move the
skeleton. The skeleton provides essential soft tissue support with joints determining the body’s
range of movement. Muscles and tendons provide the forces to actively move and control the
skeleton while also serving as active stabilizers along with ligaments and capsule giving soft-tissue
stability to joints. The nature of injury to these structures results from the application of force to
these elements.
The enthesis is classically defined as the junction between bone and either tendon ligament or joint
capsule and can be either fibrous or fibrocartilagenous in nature. Entheses are very complex
structures with classical, functional and articular fibrocartilagenous entheses now proposed. The
47
enthesis can be damaged by several aetiologies including auto-immune, infective and
biomechanical factors. The widespread nature of entheses in the body can lead to complex disease
patterns. Chronic repetitive strain is the commonest mechanism for mechanical injury of the
enthesis. Repetitive strain occurs as a result of forces large enough to damage but not cause
structural failure of the tissue. The insult is then re-applied cyclically (i.e. during training) before
complete tissue healing occurs. With each cycle the tissue weakens until eventually the force
applied is larger than the tissue tolerance and complete structural failure ensues. These forces are
usually complex as a result of differing sports and differing patient biomechanics though will have
either a predominantly passive compressive or active distractive nature. The abnormality then seen
within the enthesis is a complex combination of tendonopathy, paratendonopathy and bone changes
including bone oedema, bone erosion and proliferative new bone formation.
This lecture aims to give the delegate a wider understanding of the enthesis organ and specifically
concentrates on the types of entheseal disease seen in athletic individuals.
48
th
Saturday, 14th June, 01.00 – 2.50 p.m. – Conditions simulating rheumatological disorders –
Course VII
Chair: H. Imhof (AU), W.C.G. Peh (SI)
Abstract no. 25
SYNOVITIS IN NON-RHEUMATOLOGICAL DISORDERS
H. Imhof
Dept. of Osteology, Univ. Klin. f. Radiodianostik, Vienna, Austria
In comparison to rheumatologically based synovitis non-rheumatological ones are much more rare.
They can be caused mechanically, crystal induced, due to iron deposition and infections (septic). In
all cases pain, motion inhibition combined with synovial swelling, hyperaemia and effusion are the
first clinical and radiological signs, followed by demineralization (marginal or (and) central),
cartilage destruction and (in rare cases) and ankylosis. Radiologically the first examinations should
be ultrasound and conventional radiographs. In unclear cases an additional MR-examination with
contrast-medium application and a joint fluid aspiration should be done. Mechanically induced
synovitis depends on training environments (eg. poor technique), personal characteristics (eg.
muscle imbalance) and sport type (eg. running). Crystal induced synovitis could be based on gout,
CPPD, HADD and others. Characteristic findings are typical location, clinical findings, erosions
('overhanging margins' in gout), chondral-, synovial bursal and tendon calcifications. Iron related
synovitis is found in hemosiderotic, haemophiliac diseases and hemochromatosis. Iron may lead to
mild reactive synovitis and synovial hyperplasia. Finally, in infections (septic) synovitis typically
the knee or hip is involved, except in gonococcus-synovitis in which the wrist and metacarpophalangeal-joints may be involved as well.
Abstract no. 26
TUMOURS AND TUMOUR-LIKE LESIONS OF JOINTS
A. M. Davies
Birmingham, UK
There are numerous conditions, which may present with a mass arising from or adjacent to a joint.
This presentation is confined to monarticular disease as polyarticular disorders rarely present with
an isolated mass. As with all masses joint tumours can be classified as either benign or malignant.
Categorization as neoplastic or non-neoplastic is probably unhelpful as many benign masses are due
to synovial proliferation rather than to neoplastic change.
Benign Joint Tumours
In this category is synovial chondromatosis, pigmented villo-nodular synovitis (PVNS), lipoma
aborescens, synovial haemangioma, synovial chondroma and osteochondroma.
Synovial Chondromatosis
This is usually seen in the chronic stage where the MRI is typified by degenerative joint disease and
multiple intraarticular loose bodies [Kramer et al 1993]. In the early proliferative phase there may
49
be a large synovial mass showing cartilage calcification on the radiographs with or without joint
erosion. The synovial masses may extend some distance from the joint. The cartilage mineralisation
will appear as signal voids on MRI particularly well demonstrated on gradient echo sequences.
[Wittkop et al2002]
PVNS
This classically presents with joint swelling typified on MRI as a synovial mass with some joint
fluid. The synovial mass is characteristically of low signal intensity on all sequences due to
haemosiderin deposition from repeated intraarticular bleeding [Jelinek et al, 1998]. The mass may
be focal or generalised within the joint. For some unknown reason, focal deposits of PVNS most
commonly arise within Hoffa's fat. Erosions may occur on both sides of the joint.
Lipoma Aborescens
A rarity but distinctive on MRI T1W images show high signal intensity fronds extending into the
joint space with an effusion. [Feller et al, 1994]. The knee is the most commonly involved joint. In
approximately 10% of cases the condition is bilateral. It may also involve bursae such as the
subdeltoid.
Synovial Haemangioma
Soft tissue haemangiomas arising in the synovium are rare, accounting for less than 1% of all
haemangiomas. Young adults and adolescents are usually affected and often have a long history.
The knee is the most commonly affected joint. The appearances are those of a lobulated
intrasynovial mass, possibly containing fat with prominent serpiginous feeding vessels. Pressure
erosion of the underlying bone may occur.
Approximately one third have both intra and extra-articular components. Occasionally synovial
haemangioma may cause repetitive episodes of intra-articular bleeding. Haemosiderin deposition
may therefore mimic PVNS [Greenspan et al, 1995].
Synovial Chondroma and Osteochondroma
Extra-skeletal chondromas are uncommon. A rare subvariant is the synovial chondroma. Most cases
arise in an intracapsular location within Hoffa's fat. Other typical sites include the foot and ankle.
The appearances are those of a mass containing variable amounts of cartilage calcification. If
ossification is evident, the lesion is known as a synovial osteochondroma. If radiographs are not
obtained, the signal voids from the cartilage mineralisation may be easily mistaken for
haemosiderin deposition and the lesion in Hoffa's fat misdiagnosed as focal PVNS.
Malignant Joint Tumours
Synovial Sarcoma
Only 10% of these malignant tumours actually arise in joints [Morton et al, 1990] MRI shows a
synovial mass with bone destruction not disimilar to the early proliferative stage of synovial
chondromatosis. 30% will calcify but this is usually too fine to be appreciated on the MRI. Synovial
sarcoma will tend to show invasion of the adjacent bones rather than erosion. It is more common to
see extra-articular synovial sarcoma invading an adjacent joint rather than vice-versa.
Synovial Chondrosarcoma
A rarity but the literature does document approximately 20 cases of low grade chondrosarcoma
arising in conjunction with synovial chondromatosis [Kenan et al, 1993].
Secondary Joint Invasion
Sarcomas of bone may extend to involve the adjacent joint. It is important to recognise this feature
when staging the tumour with MRI as en-bloc excision of the tumour and joint will be required to
50
ensure synovial fluid containing malignant cells does not contaminate the surgical field. Tumour
usually penetrates the joint at capsular insertions and along ligamentous structures such as the
cruciates. Direct invasion via articular cartilage is a late feature.
Tumour-like Lesions of Joints
There are numerous mass lesions that may arise in relation to a joint. The commonest
are synovial cysts, ganglia etc [Jansen et al, 1994. Morrison & Kaplan, 2000]. The imaging features
will be briefly reviewed.
Conclusion
When a patient presents with a joint mass the possibility of a synovial-based tumour should be
considered before assuming it to be one of the more common conditions that simulate a tumour.
The emphasis of this presentation is on the value of MRI, which is ideally suited to detect and
characterize many of these lesions. However, it should be recognized that ultrasound is an excellent
technique for demonstrating many of these conditions, particularly the tumour-like lesions.
References
1. Feller JF et al (1994) Lipoma aborescens of the knee: MR demonstration. AJR 163:162-164
2. Greenspan et al (1995) Synovial haemangiomas: Imaging features in 8 cases. Skeletal Radiology,
24:583-590
3. Jansen et al (1994) Cystic lesions around the knee joints: MR imaging findings. AJR 163:155-161
4. Jelineck JS et al (1989) Imaging of PVNS with emphasis on MRI. AJR 152:337-342
5. Kenan S et al (1993) Synovial chondrosarcoma secondary to synovial chondromatosis. Skeletal
Radiology, 22:623-626
6. Kramer J et al (1993) MR appearance of idiopathic synovial chondromatosis. J Comput Assist Tomogr,
17:772-776
7. Morrison JL, Kaplan PA (2000) Water on the knee: cysts, bursae and recesses. MRI Clin N Am, 8:349370
8. Morton MJ et al (1990) MRI of synovial sarcoma. AJR 156:337-340
9. Wittkop B, Davies AM, Mangham DC (2002) Primary synovial chondromatosis and synovial
chondrosarcoma. Eur. Radiology 12. 2112-2119
Abstract no. 27
INFECTION OF THE AXIAL SKELETON
Victor Pullicino, MD
The Robert Jones & Agnes Hunt, Orthopaedic & District Hospital, NHS Trust, Oswestry, Shropshire SY10
7AG, UK
e-mail: [email protected]
Bone and soft tissue infection of the spine has a predilection for the discovertebral junction and to a
lesser extent, the facet joint articulation. Conventional radiography can be diagnostic, but MR
imaging plays a pivotal role in the diagnosis and management of spinal infection enjoying a high
sensitivity and specificity. A thorough understanding of spinal anatomy and the physico-chemical
pathological processes associated with infection, is a desirable pre-requisite allowing accurate
interpretation of the disease process. Apart from confirmation of the disease, MR imaging is also
best suited to excluding multi-focal spinal involvement and the detection/exclusion of
complications. It plays an essential role in the decision making process concerning conservative vs.
surgical treatment, and is also the best imaging method to monitor the effect of treatment. The MR
features of infection confidently exclude tumour, degeneration etc as the underlying process,
differentiate pyogenic from granulomatous infections in most cases, and can suggest the rarer
51
specific infective organisms. The use of CT is primarily in identifying bone destruction, bony debris
in the paravertebral and epidural space, the identification of gas, and in guiding biopsy approach.
Abstract no. 28
SEPTIC ARTHRITIS
K. Bohndorf
Augsburg, Germany
E.mail: [email protected] or [email protected]
As in osteomyelitis, the key factor worsening the prognosis of septic arthritis is delay in diagnosis.
Prompt diagnosis is mandatory excluding important differential diagnoses like rheumatological
disorders, transient synovitis, transient bone marrow edema, osteoarthritis and early osteonecrosis.
These differential considerations as well as the offending organisms and the potential complications
are different depending upon the age of the patient.
Extension of a metaphyseal focus of osteomyelitis is the most important route for septic arthritis in
the neonate and the hip most frequently involved. Staphylocococcus aureus and gram-negative
bacilli are the most frequent organisms inducing septic arthritis. In the neonate, the differential
diagnosis would include congenital dislocation of the hip, traumatic epiphyseal separations, and
osteomyelitis without suppurative arthritis. The complications of neonatal septic arthritis include
dislocation, epiphyseal separation, destruction of the epiphysis and end of the bone, and overgrowth
of the epiphysis and growth disturbance. Only as ossification occurs will the true anatomic result
and the degree of cartilage destruction become apparent. Three basic patterns are seen during
follow-up of neonatal suppurative joints: complete destruction of the epiphysis, a virtually normal
hip (possibly with some enlargement of the epiphysis), and the appearance of a separate ossification
center for the epiphysis, not connected by bone to the metaphysis.
Although the hip is the most frequently involved joint by septic arthritis in the child, involvement
of this joint is less frequent than is in the neonate. Joint infection is a less common complication of
osteomyelitis in the child than it is in the neonate. Suppurative arthritis in the child is frequently
preceded by a prior infection elsewhere. In children, the most common organisms are
Staphylooccus aureus and Haemophilus influenzae. The differential diagnosis includes transient
synovitis, juvenile rheumatoid arthritis, acute rheumatic fever, and osteomyelitis. Complications of
septic arthritis in the child include growth disturbances, bony ankylosis, and osteomyelitis. In the
child, a growth disturbance may result from a chronic hyperemia, or more likely, from osteomyelitis
with premature fusion of the growth plate.
Suppurative arthritis in the adult most commonly presents with very acute symptoms and limitation
of motion. The differential diagnosis in adults includes crystal arthritis, traumatic hemarthrosis, and
synovial arthritis. Complications of adult suppurative arthritis include secondary osteoarthritis,
ankylosis, osteomyelitis, soft tissue cysts and tendon ruptures.
Radiographs of joints with septic arthritis are normal in the beginning of the disease. This
especially holds true in neonates and children. Sonography is the method of first choice in case of
clinically suspected septic arthritis, whenever the anatomic location makes the use of ultrasound
possible. An effesion will be seen and a sonography-guided needle aspiration will be performed.
Aspiration fluid must be sent for gram stain as well as appropriate cultures.
MRI is a valuable tool to diagnose septic arthritis and to improve the differential diagnosis. The
combination of bone erosions with marrow edema is highly suggestive for a septic articulation; the
52
additional coexistance of synovial thickening, synovial enhancement after i.v. administration of
Gadolinium and soft tissue edema increase the level of confidence.
References:
1.
Graif M, Schweitzer ME, Deely D, Matteucci T (1999)
2.
The septic versus nonseptic inflamed joint: MRI charateristics. Skeletal Radiol 28:616-620
3.
Jaramillo D, Treves TS, Kasser JR, Harper M, Sundel R, Laar T (1995)
4.
Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR
165:399-403
5.
Bohndorf K, Imhof M, Pope TL Jr (Eds) (2001). Musculoskeletal Imaging.
6.
A concise multimodality approach. Thieme, Stuttgart, pp332
Abstract no 29
NEUROPATHIC OSTEOARTHROPATHIES
Alain Chevrot, Jean Luc Drapé
Service de Radiology B, Hôpital Cochin, AP-HP, Université Paris V, France
Aim: To describe the various patterns of this kind of trophic destruction of bones and joints due to
deprivation of sensitive feedback on the musculoskeletal system.
Summary: In case of loss of sensitivity, bones and joints deteriorate progressively without giving
subsequent pain. Destructive changes appear, sometimes already advanced at the first examination.
These changes associate modifications of the joint spaces, bony eburnation, fragmentation with
loose bodies, disorganized joint constructions, fractures and dislocation.
The causal diseases are mainly diabetes mellitus, tabes dorsalis, syringomyelia and leprosy.
X-ray examination is often very characteristic in advanced stages. Other types of imaging are not
necessary. CT scan or MRI could give more details about the destruction. They could be used for
the diagnosis of the cause, for example syringomyelia.
The involved areas of the lesion are related to the cause. Upper limb and syringomyelia. Lower limb
and diabetes mellitus. Spine and tabes dorsalis. Some treatments have been accused of creating such
diseases for example intra-articular steroid injection.
The pattern of other destructive diseases can be similar such as osteoarthritis, calcium
pyrophosphate deposition disease, calcium hydroxyapatite deposition disease, avascular bone
necrosis, psoriatic arthritis and other detritic synovitis.
The clinical context is helpful, mainly the loss of proprioceptive sensitivity. Treatment is only based
on nursing and preventive care.
Conclusion: Sometimes the cause is already known and the destruction is feared and preventive
precautions are taken.
Sometimes the destruction is discovered by imaging and leads to the subsequent diagnosis of the
cause.
53
Scientific presentations – Nortvegia Hall
th
Friday, 13th June 08.30 – 10.00 a.m. – Knee joint, Session I
Chair: F. Vanhoenacker (BE), A. H. Karantanas (GR)
Abstract no. 30 – Keynote lecture
CYSTIC LESIONS AROUND THE KNEE
F.M. Vanhoenacker1,2, S. Van de Perre1,2 , D. De Vuyst,2 , A.M. De Schepper1.
Department of Radiology1, University Hospital Antwerp, Wilrijkstraat, 10, B-2650 Edegem, Belgium
Department of Radiology2, AZ Sint Maarten, Leopoldstraat, 2, B-2800 Mechelen, Belgium
Learning objectives:
1. To give a comprehensive overview of cystic structures around the knee, based on an anatomical
approach.
2. To familiarize the radiologist with the terminology of cystic lesions of the knee.
3. To discuss the imaging characteristics that distinguish these masses.
4. To be aware of noncystic structures, which mimic true cystic lesions.
Discussion:
Recesses
Joint recesses are normal extensions or outpouchings of the joint cavity. They may be become
distented when a joint effusion occurs.
According to their location, the following recesses can be distinguished:
1.gastrocnemius-semimembranosus recess: posteromedial (Fig.1)
2.popliteus hiatus: posterolateral
3.ligamentum mucosum: anterior location within Hoffa’s fad pad
4.lateral synovial recess: lateral underneath the iliotibial band
Bursae
True bursae are synovial-lined structures that act to decrease friction between moving structures.
They are found in an anatomically predisposed topography. In normal circumstances, they are not
or barely visible, but they may become distented to various pathological conditions, including
(repetitive) trauma, inflammatory disease (rheumatoid arthritis, crystal deposition disease,…),
synovial proliferative disorders (PVNS, chondromatosis) or infection. Anatomically, the following
bursae can be distinguished: 1.suprapatellar bursa
2.prepatellar bursa
3.superficial infrapatellar bursa
4.deep infrapatellar bursa (Fig.2.)
5.pes anserinus bursa
6.medial collateral ligament bursa
7.fibular collateral ligament – biceps femoris bursa
8.semimembranosus – tibial collateral ligament bursa
When these bursae become distented, they can be characterized by its specific location, shape and
extent around the surrounding structures.
“Bursitis de novo”, occurring at not anatomically predisposed locations, have no synovial lining,
but are the result of fibrinoid necrosis of connective tissue in areas subject to chronic frictional
irritation. They are well known around a hallux valgus, but are not seen around the knee.
54
Synovial cysts
The term synovial cyst describes a continuation or herniation of the synovial membrane through the
joint capsule. In the French literature, the term „arthrosynovial“ cyst is preferred, which refers to its
intimate relationship with the adjacent joint. Indeed, there is always a communication with the
adjacent joint, and the histological composition is identical to those of the joint cavity. It consists of
a collection of intraarticular fluid, lined by a continous layer of „true“ synovial cells. Usually
associated joint diseases are present, like osteoarthrosis, inflammatory and posttraumatic joint
diseases. The elevated intraarticular pressure, due to an accumulation of joint fluid in these diseases
causes herniation of joint fluid and synovium through a “locus minoris resistentiae“ within the joint
capsule.
Ganglion cysts and variants
Ganglia contain also mucinous fluid, but their wall consists of a (discontinous) layer of flattened
pseudosynovial cells, surrounded by connective tissue (pseudocapsule).
A communication with the adjacent joint is not always present.
There remains much controversy in the literature, concerning the pathogenesis of ganglion cysts.
Several theories have been proposed, including displacement of synovial tissue during
embryogenesis, proliferation of pluripotential mesenchymal cells, degeneration of connective
tissues after trauma, and migration of synovial fluid into the cyst (synovial herniation theory).
Based upon the similar appearance on imaging, surgery and similar wall composition of synovial
cysts and ganglion cysts, we believe that the synovial herniation hypothesis is the most satisfactory.
According to this theory, synovial cysts or ganglion cysts are formed by a herniation of synovium
through a breach in the adjacent articulation.
Whereas a synovial cyst has a continuous synovial lining of true synovial cells, the wall
composition of a ganglion cyst consists of a discontinuous layer of pseudosynovial cells.
A ganglion cyst may represent an advanced stage of a degenerated synovial cyst, in which the
continuous synovial lining and the communication with the joint may be lost during the process of
degeneration.
Ganglion cysts may be located anywhere around the joints. A para-articular location in fat layers or
muscle is most frequently seen.
Special forms of ganglion cysts include meniscal cysts, cruciate ligament cysts, intraosseous
ganglia, cystic adventitial disease and peri- or intraneural cysts.
A meniscal cyst consists of a collection of synovial fluid, which is extruded through a meniscal tear.
Lateral meniscus cysts are usually located at the periphery of the middle third of the meniscus,
whereas medial meniscus cysts may present at a distant location from the joint, because of the firm
attachment of the medial meniscus to the joint capsule (Fig.3).
The identification of an associated meniscus tear and the communication of the cyst with the tear is
the key to the characterization of a meniscal cyst.
Cruciate ligament cysts occur within the fibers or on the surface of the cruciate ligaments (ACL –
PCL), and may be associated with partial tears or healed tears of the ligament.
Intraosseous ganglia are intraosseous extensions from synovial fluid through the subchondral bone.
Cystic adventitial disease is a ganglion cyst, located in the wall of vessel (popliteal artery).
Mimics of cystic lesions
Certain non-cystic lesions can mimic cystic lesions, as they are of a very high internal signal
intensity on T2-weighted images.
They include both benign (peripheral nerve sheath tumors, myxomas) and malignant tumors with
prominent areas of necrosis or myxoid degeneration (synovial sarcoma, liposarcoma,…).
Intravenous administration of contrast is mandatory in such cases to distinguish whether the
structure is (partially) solid or cystic.
Furthermore abscesses and vascular masses, such as varices and popliteal artery aneurysms may
simulate cystic lesions.
55
Conclusion: Thorough knowledge of the normal anatomy is a prerequisite to diagnose normal and
abnormal fluid-filled masses around the knee.
Ultrasound is a quick and cheap imaging method to confirm the cystic nature of the masses and to
diagnose superficial cystic structures. MRI may be indicated to demonstrate detailed anatomy and is
particularly useful in demonstrating deep located cystic masses, such as PCL and ACL cysts.
Not all masses, which display a very high signal intensity on T2-weighted images are necessarily
fluid-filled. A few non-cystic masses can mimic cystic structures. Intravenous contrast should be
administered whenever there is doubt about the cystic or solid nature of the visualized mass.
Table. Classification of para-articular cystic lesions (modified from 2)
Communication
with joint
Wall composition
Cell lining
Contents
Recess
present
continuous
mesothelial lining
„true“ synovial
cells
mucinous fluid
(Arthro)synovial cyst
present
continuous
mesothelial lining
„true“ synovial
cells
mucinous fluid
Ganglion (cyst)
maybe present
discontinuous
mesothelial lining
flattened pseudosynovial cells
mucinous fluid
Bursa de novo
absent
fibrous wall
no mesothelial
lining
fibrinoid necrosis
Bursa (permanent)
absent
continuous
mesothelial lining
„true“ synovial
cells
mucoid fluid
References:
1.
Morrison JL, Kaplan PA (2000) Water on the knee: cysts, bursae, and recesses. Magnetic Reson
Imaging Clin N Am 8: 2: 349-370
2.
Vanhoenacker F, Van Goethem JWM, Vandevenne JE, Shahabpour M (2001) Synovial tumors. In: De
Schepper AM, Parizel PM, De Beuckeleer L, Vanhoenacker F (eds) Imaging of soft tissue tumors.
Springer-Verlag, Berlin Heidelberg pp 273-300
3.
Vandevenne JE, Vanhoenacker F, Hauben E, De Schepper AM (1997) Nosologie des kystes paraarticulaires. In: Bard H, Drapé JL, Goutallier D, Laredo JD (eds) Le genou traumatique et
dégéneratif. Sauramps Médical, Montpellier, pp 293-303
4.
Malghem J, Vande berg BC, Lebon C, Lecouvet FE, Maldague BE (1998) Ganglion cysts of
the knee : articular communication revealed by delayed radiography and CT after
arthrography. AJR 170:1779-1583
56
Fig.1. Popliteal (Baker) cyst. Axial fat-suppressed T2-weighted MR image of the right knee
shows a fluid collection posteromedially in the joint extending between the semimembranosus and
medial head of the gastrocnemius tendons.
Fig.2. Deep infrapatellar bursitis. Sagittal T2-weighted MR image shows distention of the deep
infrapatellar bursa. There is also minor fluid within the superficial infrapatellar bursa.
57
Fig.3. Medial meniscal cyst extending to the intercondylar area. Coronal T2-weighted MR
image of the left knee reveals a horizontal tear within the meniscus and associated meniscal cyst.
Abstract no. 31
THE POPLITEAL HIATUS: A SPREAD PATH FOR INTRA-ARTICULAR PROCESSES OF
THE KNEE JOINT.
A.I. García, J. Bencardino*
Dept. of Radiology, Hospital Clinic, Barcelona, Spain.
*Dept. of Radiology, Massachussetts General Hospital, Boston, MA.
Purpose: The aim is to provide a clear anatomic description and MRI correlation of the popliteal
system, to show that communication between knee joint and extra-articular space through popliteal
hiatus is possible, and to illustrate examples of different intra-articular process extending to extraarticular through popliteal hiatus.
Patients and Methods, Results: Normal anatomical schemes and MRI correlation of the popliteal
system are showed. Different knee intra-articular and extra-articular process located in popliteal
tendon and popliteal muscle is presented: Synovial cyst, rheumatoid arthritis, septic arthritis,
synovial osteochondromatosis, loose bodies, lipoma arborescens, pigmented villonodular synovitis
and synovial sarcoma.
Conclusion: Popliteal hiatus may be an extension way of intra-articular process to extra-articular
popliteal tendon and/or muscle, attending to the special anatomy of this posterolateral part of the
knee. Extension by popliteus bursa promoted with knee movements or direct extension through
capsular hiatus by synovial disruption and tear capsule are differents explanation. As popliteus
bursa is linning by synovial layer, this structure can present the same lesions as synovial layer in the
intra-articular space.
Because limited arthroscopic visualization of this area, adequate diagnosis and description of these
pathologies is decisive to the management.
58
Abstract no. 32
UNEXPECTED MR IMAGING FINDINGS IN PATIENTS WITH THE CLINICAL DIAGNOSIS
OF KNEE OSTEOARTHRITIS AND MINOR OR NO PLAIN X-RAY FINDINGS
T. Nakopoulou , P. Papanagiotou, A. Zibis, T. Karachalios, AH. Karantanas
Dept. of CT-MRI, Larissa General Hospital, Larissa, Greece
Purpose: The authors sought to present the MR imaging findings in patients with the clinical
diagnosis of knee osteoarthritis.
Materials and Methods: Fourty-five consecutive patients (50 knees) were prospectively examined in
a protocol attempting to apply newer treatment options for knee osteoarthritis. All patients had minor
or no plain x-ray findings and persistent pain in the knee, diagnosed as early osteoarthritis. The
referral was from one orthopaedic department and the MRI was performed in one diagnostic center
using a 1T scanner with the following protocol: sagittal fat-suppressed (FS) PD-TSE and 3D-T1FFE-ProSet, transverse FS-T2-w TSE, coronal T1-w Spin Echo and contrast enhanced FS-T1-w Spin
Echo.
Results: In 35 knees (71.4%), typical findings of early osteoarthritis were observed. Five knees
(10%) did not show any findings relevant to osteoarthritis. Six patients (12%) showed spontaneous
osteonecrosis in the medial femoral (3) and medial tibial (3) condyle. Mild osteoarthritis was
observed in 3 patients with osteonecrosis. There were also cases with meniscal tear or grade II signal
alteration, patellar subluxation and one case with stress fracture of the tibia.
Conclusion: Spontaneous osteonecrosis is a frequent finding in patients with the clinical diagnosis of
knee osteoarthritis and MRI should be performed when plain x-ray films do not suggest degeneration.
Abstract no. 33
MRI ASSESSMENT OF KNEE OSTEOARTHRITIS: INTER-OBSERVER AND INTRAOBSERVER REPRODUCIBILITY OF A COMPARTMENT-BASED SCORING SYSTEM
P.R. Kornaat1, R.Y.T. Ceulemans1, H.M. Kroon1, N. Riyazi2, M. Kloppenburg2, W.O. Carter3, T.G.
Woodworth3, J.L. Bloem1
1
Dept. of Radiology, 2 Dept. of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands; 3
Pfizer Groton, Groton, CT, USA.
Purpose: To develop a scoring system for quantifying osteoarthritic changes of the knee as
identified by MRI in patients with known osteoarthritis, and to determine its inter- and intraobserver reproducibility.
Materials and Methods: Two independent observers evaluated twenty-five consecutive MR
examinations of the knee in patients with previously defined clinical symptoms and radiological
signs of osteoarthritis. Images were scored for the presence of diffuse cartilage loss, focal chondral
and focal osteochondral lesions. The images were also scored for the presence and size of marginal,
intercondylar or central osteophytes, subchondral cysts, bone marrow edema, and for meniscal
abnormalities such as intrasubstance degeneration, subluxation and tear. Presence and size of an
effusion, synovitis and Baker’s cyst were recorded. All parameters were ranked on a previously
59
defined, semiquantitative, 0 through 3 scale. Kappa, weighted kappa and intraclass correlation
coefficient (ICC) were used to assess inter- and intra-observer variability.
Results: Inter-observer variability measured by ICC’s ranged from 0.45 for focal chondral defects
to 0.91 for bone marrow edema (median 0.72). For intra-observer variability, overall ICC’s ranged
from 0.63 to 0.96 (median 0.79).
Conclusion: This paper presents a MR scoring system for osteoarthritic changes of the knee with
good to very good inter-observer and intra-observer reproducibility.
Abstract no. 34
MRI OF THE KNEE AFTER UNREAMED INTRAMEDULLARY NAILING OF TIBIA
J. Gustafsson, S. Toksvig–Larsen, K. Jonsson
Center of Imaging and Physiology, University Hospital Lund, Lund Sweden
E-mai: [email protected]
Aim: To analyse the reason for knee pain after intramedullary nailing of tibia fracture.
Patients and Methods: Ten patients, eight men and two women aged 15-52, mean 30 years were
examined and nail extirpated 9-29, mean 14 months after nailing. All patients had different degree
of knee pain after nail extirpation. The examinations were performed with standard MRI sequences,
including STIR, 2-45, mean 26 months after nail extirpation.
Results: In all patients we found signal changes of fluid in the remaining channel of the extirpated
nail, together with metal artefacts of varying degree. Hoffa’s fat pad contained areas of low signal
intensity. The patellar ligament showed some degree of thickening and subcutaneous low-signal
nodes in front of the ligament in all patients. In nine patients we found low-signal adhesions from
the operation site/exit hole towards the patellar ligament. In four of the patients we found meniscal
rupture and/or local cartilage damage.
Conclusions: The degree of adhesions towards the patellar ligament reflects the degree of knee
pain. One patient with no adhesions had been more or less pain free for more than a year. Meniscal
rupture and local cartilage damage seems to be incidental findings.
Abstract no. 35
RADIOLOGY OF THE KNEE IN DIASTROPHIC DYSPLASIA
A PRE- AND POSTOPERATIVE STUDY
Lohman M, Tallroth K, Helenius I, Remes V, Poussa M, Helenius M, Paavilainen T
Dept. of Radiology, University of Michigan, Ann Arbor, MI 48109-0030, USA
Study performed at: Orton Orthopedic Hospital, Helsinki, Finland
Aim of the study: Diastrophic dysplasia results in severe disproportionate short stature, generalized
joint deformities, and early osteoarthritis. The aim of the study was to evaluate the radiological
findings of the knees before and after arthroplasty.
60
Patients and methods: The radiological findings, including assessment of the deformations and
malposition in 21 knees of 14 patients with diastrophic dysplasia were analyzed both before and
after total knee arthroplasty. The average age of the patients was 44 years at the time of
arthroplasty; the mean postoperative follow-up time was 3.4 years.
Results: Preoperatively all patients had severe clinical symptoms. X-rays showed osteoarthritis and
marked radiological deformities: excessive valgus, a low-lying and often laterally displaced patella,
and pathologic metaphyseal angulation of both distal femurs and proximal tibiae. The arthroplasties
were successfully done and none of the knees required revision. The radiological findings and
measurements are demonstrated more profoundly at the oral presentation. The clinical results of the
knee arthroplasty were good with decreased pain and increased function.
Conclusions: The total knee arthroplasty improved substantially the function of patients with
diastrophic dysplasia. Preoperative radiologic measurements must be carefully done as the
deformities are so marked. Some knees need special custom-made prostheses. Correction of
malposition of the joints is also demanding and requires a thorough preoperative planning with
weight-bearing radiographs of extremities.
Abstract no. 36
QUANTIFICATION OF KNEE JOINT ANGULATION WITH AXIS MEASUREMENT OF THE
LOWER EXTREMITY ON CONVENTIONAL AND DIGITAL RADIOGRAPHS
J. Sailer, M. Scharitzer, P. Peloschek, A. Guirea, S. Grampp
Dept. of Diagnostic Radiology, University of Vienna, Vienna, Austraia
E-maail: [email protected]
Purpose: To assess valgus and varus angulation of the knee joint using mechanical axis
measurement of the lower extremity on conventional and digital radiographs.
Material and Methods: Total leg radiographs of 24 patients, 8 male and 16 female, mean age
68.6±10.2 years, were performed in a standardized anteriorposterior projection and standing
position. We used a conventional film screen radiography system (size 20 x 96 or 30x120) for
original size radiographs with measurement grid and a ADC full body cassette holder with three
ADCC/MD phosphor storage plates (14/17“) for digital radiographs (AGFA-GEVAERT, Belgium)
in the same patients. Knee joint angulation was assessed measuring the angle between a line drawn
from the center of the femoral head to the middle of the femoral condyles and a line drawn from the
middle of the tibial condyles to the midpoint of the malleolus. On conventional leg radiographs line
drawing and angle measurement was performed manually with a transparent goniometer. Angle
measurement on digital leg radiographs was undertaken on a PACS workstation using a computer
assisted measurement software (IMPAX, AGFA-GEVAERT, Belgium).
Results: We diagnosed 14 varus and 10 valgus angulations of the knee joint. The mean total axis
deviation on conventional radiographs was 6.71°±3.84° (min 1°, max 14°). Equivalent data for the
digital radiographs were 6.08°±3.67° (min 1°, max 13.9°). The mean individual difference between
axis deviation of conventional digital leg radiographs was 0.93°+0.6° (min 0°, max 2°). We did not
find any statistically significant differences. Total time used was 118 minutes (mean 4.9
minutes/patient) for manual and 26 minutes (mean 1.08 minutes/patient) for computer assisted
angle measurement (p< 0.001).
61
Conclusion: Computer assisted angle measurement on digital total leg radiographs represents a
reliable method with no significant angle differences compared to conventional radiographic
systems and provides a significantly lower evaluation time.
Abstract no. 37
PAINFUL BIPARTITE PATELLA: MRI CHARACTERISTICS
F.M. Vanhoenacker1,2, S. Van de Perre1,2, A. Bernaerts1, L. De Beuckeleer1, A.M. De Schepper1
Dept. of Radiology1, University Hospital Antwerp, Wilrijkstraat, 10, B-2650 Edegem, Belgium
Department of Radiology2, AZ Sint Maarten, Leopoldstraat, 2, B-2800 Mechelen, Belgium
Purpose: To discuss the MRI characteristics of painful bipartite patella.
Methods and Materials: We report five patients presenting with knee pain at the patellar bone.
The age of the patients ranged between 18 and 39 years.
Radiographs revealed a bipartite patella in all patients. The accessory fragment was located at the
superolateral pole of the main patellar bone in two patients, whereas a lateral or inferior location
was found in two and one patient respectively.
On MRI, there was high signal intensity on the fat-suppressed T2-weighted images within the
accessory ossification center and the main body of the patella. This pattern was consistent with
bone marrow edema on both sides of the fibrocartilaginous junction between both patellar
fragments.
Results and Conclusions: 1) Bipartite patella is a common asymptomatic finding. Its painful
variant is rare and is usually seen in young athletic adults. The occurrence in non-athletic older
patients, like two of our patients, is exceptional. 2) Standard radiographs cannot distinguish
asymptomatic and symptomatic variants. 3) MRI can provide invaluable diagnostic information in
the symptomatic variant, by demonstration of bone marrow edema within both adjacent fragments
of the patella on fat-suppressed T2-weighted images.
62
th
Friday, 13th June 10.30 – 12.00 a.m. – Hip joint and fee - Session 2
Chair: K. Tallroth (FI), S. A. Bus (NL)
Abstract no. 38 - Keynote lecture
RADIOLOGICAL EVALUATION OF THE DYSPLASTIC HIP IN PATIENTS UNDERGOING
GANZ OSTEOTOMY
Kaj Tallroth, M.D., Ph.D., F.I.C.A.
ORTON Orthopaedic Hospital, Dept. of Radiology, P.O. Box 29, FIN-00280 Helsinki, Finland
A variety of different radiological measurement methods have been used to diagnose and quantify
dysplasia of the hips. Many of the methods based on conventional radiology have been replaced by
computed tomography (CT), which has proven to be more accurate for the planning and simulation
of pelvic and femoral osteotomies. This presentation describes methods that are found to be
convenient and accurate for routine diagnostic work as well as for demanding preoperative analysis
in three dimensions. The primary deformity in the acetabular dysplasia of adults is a dysplasia with
poor anterior, lateral or posterior containment of the femoral head. Lateral deficiency is common for
all patients. As the conditions vary widely in individuals, a thorough analysis in three dimensions of
the coverage based on CT volume scanning is crucial prior to surgery.
Acetabulum
Congruity of a hip joint means that the articular surfaces of the acetabulum and femoral head fit
each other. If one of the surfaces for some reason is deformed it will lead to deformity of the other
surface (Fig. 1). Malformation can be due to a congenital hip dislocation, a previous infection, or a
developmental disturbance such as Legg-Perthes or a slipped epiphysis. Usually all these
deformities are obvious on ordinary AP and frog-view radiographs. A superior subluxation of the
femoral head is best appreciated on the AP radiograph as a step-off in the Shenton's line (Fig. 2).
Containment of the hip joint means coverage of the femoral head by the acetabulum. For the
assessment of the lateral coverage on AP radiographs, the CEA angle of Wiberg (Fig. 3) is used.
This is perhaps the easiest and fastest way to determine the degree of lateral coverage. For partial,
but not conclusive readings of the superoanterior coverage, a projection called false profile has been
used.
Lateral tilt of the opening of acetabulum (AC-angle) is easily measured from a AP radiograph. The
AC-angle is the angle between the horizontal plane of the pelvis and the line connecting the
superior edge of the fovea with the lateral rim of the acetebulum (Fig. 3).
The most accurate information about the coverage of the acetabulum in all three dimensions is
obtained from CT scans. For the scanning the patient is positioned supine in the gantry with the feet
in neutral rotation. An AP scout view is used to ensure that the pelvis is in horizontal position by
checking the location of the inferior edges of the sacroiliac joints. A low dose helical scanning
technique provides data for 2D reformatted images of the hip in any plane. The superoanterior and
lateral coverage of the femoral head are assessed from reformatted images through the center of the
femoral head (Fig. 4).
All measurements should be corrected for the difference between the recumbent scanning position
and the weight bearing upright position.
63
The anteversion of the acetabulum is measured from a 2D reformatted image through the centers of
both femoral heads (Fig.5). From the same image the anterior and posterior coverage of the
acetabulum are measured.
Femur
The femoral neck and head are as important for the congruity and containment of the hip joint as the
acetabulum. Before correction of a malposition of the head radiographs of the hip in abduction and
adduction are performed to see whether the reoriented head fits into the acetabulum (Fig. 6).
Today CT is widely used for measurement of the anteversion of the femoral neck. (Fig. 7). Low
dose scans are taken through the neck of femur and distal femur at the level of the condyles.
Calculations performed on a workstation with rotation of the femoral parts make the technique
extremely accurate, since it is not dependent of the position of the extremities during scanning.
The easiest way to judge the neck-shaft angle from an AP radiograph of the hip is to draw a line
through the tip of the greater trochanter perpendicular to the long axis of the femur. Normally, this
line runs through the center of the femoral head but in coxa vara the line runs above it and in coxa
valga below the center (Fig. 8). This relationship between the tip of the trochanter and the center of
the femoral head is independent of the rotation of the leg.
Flexion of the neck-head is a rare condition, which can be identified on ordinary AP radiographs as
a double contour of the femoral head. This malposition leads to a deficiency of the superoanterior
coverage of the femoral head. The condition is well demonstrated with 3D images rendered from
data obtained in CT volume scanning (Fig. 9).
Post-operative evaluation
The same radiological examination and measurements are postoperatively performed to evaluate
how the preoperative planning and the outcome of the surgery have succeeded. On plain films the
leg length equality as well as the horizontal balance of the pelvis are seen. The AC and CE angles
reveal how the surgery has corrected the faulty containment. Healing of the supra-acetabular part of
the Gantz osteotomy is easily appreciated while the union of the posterior part and the osteotomy of
the upper ramus are frequently not detectable due to unfavourable projections or superimposition of
other bone structures. There is no need for additional oblique plain x-rays when CT is used as the
union of the entire osteotomy is well demonstrated with CT 2D curved reformatted images (Fig.
10). The AC and CE angles are measured in sagittal and coronal CT reformats through the centre of
the femoral head and compared to the preoperative values.
Failed corrections of femoro-acetabular congruency, either because of a too extensive correction or
a too small one, can be concluded from the plain and CT films. An intra-operative fracture of the
base of the lower ramus just under the acetabular joint is not uncommon. However, this usually
heals in 4-6 months. A lasting non-union of the upper ramus osteotomy is more frequent. According
to postoperative clinical evaluations of Gantz patients this non-union does not cause pain or
discomfort for the patients.
These measurement methods make it possible to truly identify and quantify the congruity,
containment and position of the articular parts of the hip joint. This is crucial in order to improve
both the primary diagnosis of hip dysplasia and the preoperative planning of the surgery to obtain
an optimal head coverage as well as the congruity of the joint.
References
1. Anda S: Evaluation of the hip joint by computed tomography and ultrasonography. Dissertation,
University of Trondheim,1991.
64
2. Dihlman W: Topographic radiologic diagnosis of the gliding tissues. In: Joints and vertebral
connections, p.77-375, Thieme, New York, 1985.
3. Ganz R, Klaue K, Son Vinh T, Mast JW: A new periacetabular osteotomy for the treatment of hip
dysplasias. Clin Orthop 232: 26-36,1988.
4. Janzen DL, Aippersbach SE, Munk PL, Sallomi DF, Garbuz D, Werier J, Duncan CP:
Three-dimensional CT measurement of adult acetabular dysplasia: technique, preliminary results in
normal subjects and potential applications. Skeletal Radiol 27:352-358,1998.
5. Maue K, Wallin A, Ganz R: CT evaluation of coverage and congruency of the hip prior to osteotomy.
Clin Orthop 232:15-25,1988.
6. Murphy SB, Kijewski, Millis MB, Harless A: Acetabular dysplasia in the adolescent and young adult.
Clin Orthop 261:214223,1990.
7. Weissman BNW, Sledge CB: The hip. In: Orthopedic radiology,p. 385-495, Saunders, Philadelphia,
1986.
Fig.l. Hip dysplasia; both the acetabulum and the femoral head are deformed.
Fig.2. A step-off of the Shenton's line indicates a cranial subluxation of the femoral head
65
Fig.3. Measurements of the CEA and AC angles on a radiograph. Additionally the leg length
disparity and the lateral tilt of the pelvis are measured.
Fig.4. CEA and AC angles are measured on the coronal CT reformatted images (a) and the
superoanterior coverage on the sagittal reformation (b). Both measurements are done through
the center of the femoral head.
Fig.5. On a reformatted image through the centers of the femoral heads the anterior and
posterior coverages are measured to the left and the acetabular anteversion to the right.
66
Fig.6. The drawing to the left shows how the femoral head moves into acetabulum in
abduction.
Fig.7. The tilt of the femoral neck in relation to the bicondylar line demonstrates the
anteversion of the femoral neck.
Fig.8. The left drawing shows a varus neck-shaft angle, the one in the middle a normal angle
and the drawing to the right a valgus position.
67
Fig.9. The preoperative 3D images in the upper row show an anterior flexion of the
head-neck. The postoperative images (lower row) show how the deformity was corrected
with a posterior wedge osteotomy
Fig.10. Curved CT reformatted image demonstrates a fused supra-acetabular osteotomy and a
non-fusion of both the superior and inferior ramus.
Abstract no. 39
MULTISLICE CT IN EVALUTION OF TOTAL HIP ARTHROPLASTY
M. Maes, B. Bohy, J. Gielen, R. Nuyts, A. De Schepper
Dept. of Radiology, University Hospital, University of Antwerp, Belgium.
Purpose: To evaluate the additional value of multislice CT in the evaluation of total hip
arthroplasty.
Patient and Methods: Patients were selected at random by the orthopedic department. The
inclusion criterium was one or two total hip prosthesis, operated at least one year ago. Surgery was
planned on basis of X-ray, scintigraphy, laboratory and clinical findings, without knowledge of CTimaging results.
68
A clinically blinded multislice CT examination of one or both hips was performed using a Siemens
Sensation 16® scanner. Examinations were viewed as 3 mm thin multiplanar reconstructions in
three orthogonal planes. Findings were prospectively correlated with X-ray, scintigraphic, clinical
and peroperative findings.
Results: Data was acquired for 22 protheses in 15 patients. CT Findings: cup loosening(7), stem
loosening(4), malpositioning(2), luxation(1), PE wear(1), fracture of circling wires(1) and
infection(1).
For detection of cup loosening multislice CT has a sensitivity of 100%, a specificity of 100%, a
PPV of 100% and an NPV 76,2%. For detection of stem loosening sensitivity is 100%, specificity
100%, PPV 100% and NPV 85,7%
Conclusion: Multislice CT is a powerfull tool for evaluation of total hip arthroplasty.
Abstract no. 40
HIP JOINT SPACE AREA IN STANDING AND SUPINE RADIOGRAPHS
L. Niemitukia
Dept. of Clinical Radiology, Kuopio University and Kuopio University Hospital, Finland
Purpose: To find out differences in hip joint space area of healthy and osteoarthritic hip joints in
standing and supine radiographs.
Patients and Methods: The material consisted of 36 voluntary men aged 45-64 years with uni- or
bilateral hip osteoarthritis, and 32 healthy age-matched controls. Osteoarthritis was graded by Li.
There were 14 grade I, 10 grade II and 12 grade III hip joints, and no grade IV joint. Joint spaces
were measured by image processing software by IpLab: joint spaces were divided to 12 sectors of
10 degrees, centre point in the middle of femoral caput and the areas were measured. Lateral,
intermediate and medial thirds were analysed. Statistical analysis was made by Student’s t-test.
Results: The ratio between supine/standing position was remarkably different in the intermediate
sector of grades 0 (112%, p<0.001) and II (115, p<0.01), and of grade I in the lateral (117%,
p<0.001) and the intermediate (114%, p<0.001) sectors.
Conclusion: In the intermediate area the hip joint narrows on standing compared to supine position
both in normal and in mildly osteoarthritic hip joints of middle-aged men.
Abstract no. 41
EFFECTIVENESS OF INTRAARTICULAR STEROID INJECTION IN OSTEOARTHRITIS OF
THE HIP
P. Robinson, P. Conaghan, P.A. Duffin, M.J. Hampshire, B.D. South, J.J. Rankine
Chancellor Wing X-ray, Leeds Teaching Hospital, St. James University Hospital, Leeds, UK
Purpose: To assess the effectiveness of intraarticular steroid hip injections in osteoarthritis.
Methods and Materials: After institutional ethics approval consecutive patients with osteoarthritis
referred for intraarticular steroid hip injection were prospectively included. Data recorded included
69
age, body mass index (BMI) and WOMAC likert scores at baseline, conventional radiographic
severity (Kellegren and Lawrence scoring (KL=0-4)) and ultrasound capsular thickness (normal,
mild, moderate and severe). Repeat WOMAC scores were obtained at 6 and 12 weeks after hip
injection. Friedman analysis was performed on change scores from baseline for each of the 3
WOMAC subscales (pain, stiffness, function).
Results: To date 53 patients have been recruited (mean age 64.5). Mean BMI 27.4, median
conventional radiograph grade KL3, median capsular thickness was moderate. Overall for
WOMAC scores there was only a significant difference for reduced stiffness at 6 weeks (p=0.002)
with no significant differences in any symptoms at 12 weeks. Conventional radiograph severity did
not relate to baseline symptoms. However, hips classified as having moderate to severe capsular
thickening showed higher baseline pain and stiffness scores.
Conclusion: The results of this prospective study do not demonstrate a long-term benefit for
intraarticular steroid injections in osteoarthritis of the hip.
Abstract no. 42
TRANSIENT OSTEOPOROSIS OF THE HIP: MR IMAGING PATTERNS AND PERFUSION
CHARACTERISTICS ON CONTRAST-ENHANCED DYNAMIC IMAGING
A.H. Karantanas, A.H. Zibis, T. Nakopoulou, P. Papanagiotou, S. Varitimidis, Z. Dailiana, K.N.
Malizos
Dept. of CT-MRI, Larissa General Hospital, Larissa, Greece
Purpose: To review the MRI findings in transient osteoporosis of the hip (TOH) and to investigate
the pattern of perfusion in dynamic studies.
Methods and patients: We reviewed 27 patients, (29 hips), 23-66 year-old, referred for hip pain
without any history of trauma. In all patients the diagnosis of TOH was confirmed with x-rays
(decrease bone density of the femoral head), MRI (bone marrow edema-BME) and complete
resolution of symptoms after 6-18 months. MRI studies included T1-w SE, T2-w-SPIR-TSE and
contrast enhanced T1-w TFE in dynamic mode and delayed SE. Imaging assessment included joint
effusion, location and extent of BME (types A-D), sparing of the femoral head, subchondral linear
lesions, and collapse.
Results: 18/19 of hips had joint effusion. The extent of BME in head was type A in 5/29 hips, B in
2/29, C in 16/29, D in 6/29. There was associated BME in acetabulum in 6/29 hips. In 12/29 hips
the bone marrow edema was sparing the subchondral area. Subchondral line was found only in 2/29
hips. On dynamic T1 W images all hips were presented with a delayed pattern of perfusion up to 40
sec.
Conclusion: MRI findings are useful in differentiating TOH and early AVN.
70
Abstract no. 43
DISTAL FAT PAD DISPLACEMENT IN DIABETICS WITH NEUROPATHIC FOOT
DEFORMITY: MR EVALUATION
S.A. Bus, M. Maas, R.P.J. Michels, M. Levi.
Depts. of Internal Medicine and Radiology, Academic Medical Center, University of Amsterdam,
Amsterdam, The Netherlands.
Aim: To examine the effect of metatarsal-phalangeal (MTP) joint hyperextension deformity in the
foot on the architecture of the sub-metatarsal head (MTH) fat pad in patients with diabetes and
peripheral neuropathy.
Material and Methods: Thirteen diabetic subjects (8 males, mean age 56.2 yrs.) with sensory
neuropathy and toe deformity and 13 matched diabetic neuropathic controls (mean age 57.4 yrs.)
with no deformity participated. A 1.5 Tesla MR scanner was used. Sagittal high-resolution
(512x512 matrix) T1-weighted spin echo images of the forefoot were acquired from which subMTH and sub-phalangeal fat pad thickness was measured. The ratio of these two measures was
indicative for fat pad displacement.
Results: The mean (sd) sub-MTH fat pad thickness was 3.0 (1.6) mm in the experimental group
compared to 6.5 (2.0) mm in the controls (p<0.001). The ratio was 0.29 (sd 0.16) in the subjects
with deformity and 0.73 (sd 0.17) in the controls (p<0.001) reflecting distal fat pad displacement in
the deformed feet.
Conclusion: These results suggest that the sub-MTH shock-absorbing capacity is severely
compromised in feet with toe deformity. This is expected to result in elevated dynamic plantar
pressures and a higher risk for plantar ulceration in these patients who have lost protective
sensation.
Abstract no. 44
DIABETIC FOOT COMPLICATIONS, ROLE OF MEDICAL IMAGING IN THE
DIFFERENTIAL DIAGNOSIS OF OSTEOMYELITIS, CHARCOT ARTHROPATHY AND
CELLULITIS IN DIABETIC FOOT PATHOLOGY: A PROSPECTIVE STUDY IN 53
PATIENTS.
P. Van Dyck, J. Gielen, I. Huyghe, A. De Schepper, K. Van Acker
Dept. of Radiology, University Hospital of Antwerp Belgium, Belgium
Aim: To evaluate the diagnostic accuracy of plain radiography, nuclear medicine and MRI, in the
diagnosis of diabetic foot complications.
Patients and Methods: We prospectively examined 53 patients with diabetic foot complications
with Tc-whole-body bone scintigraphy, plain radiography and MRI (T1-WI, T1-WI FS before and
after gadolinium injection and with subtractions and T2-WI). 42 patients had nanocolloid
scintigraphy.
Osteomyelitis was diagnosed on MRI by the combination of intra-osseous and soft tissue edema,
both enhancing after IV Gd administration. MR features of Charcot arthropathy included bonemarrow edema with enhancement after IV Gd, without associated soft tissue abnormalities.
Cellulitis only was characterized by enhancing soft tissue swelling.
71
Results:
Osteomyelitis
Sensitivity
MRI
100
Radiography
28
Scintigraphy
94
Charcot
MRI
95
Radiography
55
Scintigraphy 100
Cellulitis
MRI
94
Radiography
25
Specificity
100
100
62
100
100
88
100
15
PPV
100
100
79
100
100
83
100
100
NPV
100
48
87
97
79
100
67
100
Accuracy
100
57
81
98
83
93
94
13
Conclusion: MRI is the imaging modality of choice for evaluation of diabetic foot complications.
Our study showed improved diagnostic accuracy for the MR diagnosis of osteomyelitis when
compared with literature findings, due to the use of T1-WI FS before and after gadolinium injection
and subtraction. This dedicated MR protocol will be helpful in the differential diagnosis of
osteomyelitis, Charcot arthropathy and cellulitis in diabetic feet.
Abstract no. 45 - withdrawn
72
th
Friday, 13th June, 01.00 – 02.30 p.m. – Intervention - Session 3a
Chair: W.R. Obermann (NL), F. Aparisi (ES)
MODERN TECHNIQUES IN CT GUIDED INTERVENTIONS OF THE MUSCULOSKELETAL
SYSTEM.
Wim R. Obermann, MD, PhD
Department of Radiology, LUMC, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
Framework: Imaging techniques: CT, CT fluoro single slice and multislice. Navigation devices.
Needles. Approach.
Imaging techniques.
Using CT imaging precise and demonstrated needle placement in bone and soft tissue lesions can be
achieved. This is important for biopsies to be taken as well as for treatment options like RF ablation
of small bony lesions like osteoid osteomas. The CT guided puncture can be done using
conventional CT, or CT fluoro either single slice or multislice. In either modality a plane scan with
a ladder of catheter material placed on the skin to plan the entrance point should be taken. Knowing
the slice to approach the lesion and the angulation in the scan plane, the entrance point on the skin
will be the crossing of the gantry laser beam corresponding with the slice position and a certain
ladder step corresponding with the angulated planned puncture line passing the skin. For precise
needle position, puncturing in the scan plane is the best option.
After the plane scan the needle should be placed in the right direction and the position of the needle
can be checked by one or several control CT slices. This can be done on the conventional way, or
by CT fluoroscopy. With CT fluoroscopy separate images can be obtained on a quick manner by the
radiologist. With a single slice CT fluoroscopy devise the delay to obtain a single view after
pushing the foot pedal is 1 second and the maximum number of images is 6 per second
(reconstruction time or delay 0.17 seconds). The delay with a multislice CT fluoroscopy devise is
0.3 seconds and the maximum number of images is 12 per second (reconstruction time or delay
0.083 seconds), using 1 frame.
With both types of devices fluoroscopy can be performed during needle advancement or during
movement of the tabletop for searching the needle tip. Both methods of fluoroscopy are not
advisable in musculoskeletal work. For example in bone drilling the best position is besides the
patient with the patient outside the gantry. The devises do not have a memory of the fluoroscopy;
they only show the last fluoroscopic image. Moving the tabletop during fluoroscopy for searching
the needle point is therefore not practical as by the delay of the reconstructed images the last image
has always passed the position of the needle tip. The radiation exposure for the patient and the
radiologist is also much higher using real fluoroscopy instead of using the fluoroscopy as quickcheck method with one or several slices after each other. In a study comparing the conventional CT
method with the quick-check method using a CT fluoro device, we showed that the radiation dose
was even less with the last method (1).
Navigation devices.
There are simple navigation devices like a laser goniometer in which the angulated laser beam
should reflect on the needle when the needle is correctly angulated. With two devices it is possible
to angulate in two directions.
73
A more sophisticated navigation system is e.g. an optical navigation system in which the gantry, the
patient and the tool holder are defined in space by ILED’s. After a planning scan the trajectory of
the needle can be chosen (also outside the scan plane by multi-planar reconstruction). A computer
simulates the puncture pathway during the puncture. A check scan remains necessary to control the
real position of the needle. The big advantage of this last system is a precise puncture in every
desired direction outside the scan plane. The disadvantage is the more handling procedures.
Needles.
For bone biopsies Jamshidi type needles with a tapered tip are suitable (8 G and 11 G) (2). When
the bone process is very lytic or for soft tissue components or soft tissue tumors Thru-cut needles
used with a coaxial system are suitable (14 G). Using a coaxial system several passes in different
directions can be done by angulating the outer cannula in different directions. When appropriate
also smaller needles (16 or 18 G) can be used.
The Bonopty system with an outer cannula of 14 G and inner side used (asymmetrical) drills and
biopsy devices (3) is very suitable as guidance for RF ablation needles in osteoid osteomas and
osteoblastomas.
Of course also one step drains for drainage of paravertabral and intravertebral abcesses are in the
armature of CT guided musculoskeletal interventions.
Approach
In most cases a direct approach to a bone or soft tissue lesion is well possible provided that the
approach in primary tumors is consulted with the orthopaedic surgeon in order not to compromise
the anticipated surgical approach to the lesion. Sometimes an approach through the opposite cortex
is safer with respect to vital neurovascular structures close to the lesion.
For some mediastinal or présacral masses or fluid collections an approach through the sternum or
the sacral bone can be advantageous and should be considered.
References:
1.
Teeuwisse WM, Geleijns J, Broerse JJ, Obermann WR, Van Persijn Van Meerten EL. Patient and staff
dose during CT guided biopsy, drainage and coagulation. Br J Radiol 2001; 74:720-726.
2.
Jamshidi K, Swaim WR. Bone marrow biopsy with unaltered architecture: a new biopsy device. J Lab
Clin Med 1971; 77:335-342.
3.
Ahlström KH, Aström KGO. CT-guided bone biopsy performed by means of a coaxial bone biopsy
system with an eccentric drill. Radiology 1993; 188:549-552.
Abstract no. 47
VERTEBROPLASTY (VP) GUIDED BY CT FLUOROSCOPY - OUR EXPERIENCE OCT 99'APRIL 2003
E. Pérez, J. Serra, A. Muntané, M. Rovira, J.A. Narváez
Dept. of Radiology, Ciutat Sanitària de Bellvitge, Barcelona, Spain
Purpose: To evaluate the benefits of CT fluoroscopy in PVP as a method of guide.
Material and methods: During a period of 42 months, we have treated with PVP 101 collapsed
vertebras in 79 patients ( 63 dorsal, 38 lumbar), using CT fluoroscopy as a method of guide.
In every case, either the way of entrance was pedicular, juxtapedicular or posterolateral, we have
made a surview checking the position and direction of the needle inside the vertebral body.
74
Once the needle was in a correct position, we have injected the cement controlling the way and
direction in which it expands in the vertebral body, by using CT fluoroscopy, moving the table
position and stopping it when it was close to the posterior wall.
Results: Patients have experienced an important relief of pain in 98% of cases. Patient selection is
of considerable importance. No important complications ocurred in our serie. Extravasation to
intervertebral disk, paravertebral space and into epidural veins were described without a significant
clinical incidence.
Conclusions: CT fluoroscopy is a very good and reliable guide to perform percutaneous
vertebroplasty in trained hands, obtaining important pain relief and contributing to stabilize the
spine.
Abstract no. 48
MID-TERM CLINICAL RESULTS AFTER PERCUTANEOUS VERTEBROPLASTY
R.T. Hoffmann, A. Wallnhöfer, M.F. Reiser, T. Helmberger
Institute of Clinical Radiology, Klinikum Grosshadern, University of Munich, 81377 Munich, Germany
Purpose: Outpatient vertebroplasty is increasingly performed for pain relief and stabilization in
osteoporotic vertebral fractures and osteolytic neoplastic lesions of the spine. The aim of our study
was to evaluate mid-term clinical results after percutaneous vertebroplasty for severe back pain
caused either by metastases, tumors or osteoporosis.
Material and Methods: Within one year 62 procedures were performed in 49 consecutive patients
(32f, 17m, mean 67 years) with malignant (n=25, 6 plasmocytoma,
19 metastases) or benign (n=24, osteoporosis) disease to the spine. Vertebroplasty was performed
under CT-guidance only with local anesthesia. We evaluated the efficacy of therapy in terms of pain
relief at dismissal and after a time period of up to 1 year using a standardized questionnaire (pain,
medication, additional treatment).
Results: 61 of 62 procedures were technically successful with no significant unwanted distribution
or leakage of cement and were very efficacious in relieving pain. 85 % of all patients report good or
very good pain relief after vertebroplasty, while in 7% only pain reduction and in 8% no significant
effect was noticable. No major complications were observed.
Conclusion: Percutaneous vertebroplasty offers effective, minimally invasive treatment for severe
back pain with excellent mid-term results in malignant and benign disease.
Abstract no. 49
TREATMENT OF JUXTA-ARTICULAR CYSTS WITH A BIOLOGICAL PRODUCT
F. Aparisi, C. Cifrian, J. Beltran, F. Valenzuela, C. Miguel
Hospital La Fe Valencia and Clinica Virgen del Consuelo Valencia, Spain.
Introduction and purpose: The bony cystic lesions located in the vicinity of the joints in occasions
are responsible of very important articular symptoms so that they end up making necessary the
75
substitution by means of prosthesis. In occasions these juxta-articular lesions are presented in young
patients or in areas that are not possible the prosthesis substitution.
Patients and Methods: Six patients have been selected with bony defects, five are juxta-articular
cyst and the sixth one presents a vertebral lesion labeled as aneurismal bone cyst. To treat these
patients there have been injected hidroxiapatite using a 14 G needle and a vertebroplasty injector.
Results: The follow-up of these patients is presented. MRI, CT and X ray give us information about
the incorporation of this bone precursory product that doesn't produce inflammatory reaction and
can be used as a reparative element with a minimum risk.
Abstract no. 50
IS THERE A NEED FOR ANTIMICROBIAL PROPHYLAXIS IN PROVOCATION
DISCOGRAPHY
S. Chaudhary, T. Muthukumar, D. Wardlaw, F.W. Smith
Orthopaedics, Woodend Hospital, Radiology, Aberdeen Royal Infirmary and Radiology, Woodend Hospital,
Aberdeen, UK
Purpose: Role of antimicrobial prophylaxis in discography remains controversial. Discitis after
discography has an incidence of 0.1% - 0.2%. North American Spine Society consider prophylactic
antibiotics as optional in their position statement on lumbar discography (1995). Others consider it
negligent not to have used prophylactic antibiotics. This retrospective study evaluated incidence of
discitis without antimicrobial prophylaxis and assess need for antimicrobial prophylaxis.
Material and Methods: All consecutive discography examinations carried out at Woodend
Hospital, Aberdeen, UK between January 1991 and December 2000 were retrospectively evaluated.
The procedures had been carried out without antimicrobial prophylaxis.
Results: 1368 patients had discography at 3197 levels. 299 of these patients were examined by
radiologists and 1069 patients by Orthopaedic surgeons. Patients were followed up over a mean
period of 5.56 years. One patient developed discitis at one level, giving 0.073% infection rate per
patient and 0.031% infection rate per disc examined.
Conclusion: Our experience supports the fact that if experienced operators perform the
examinations under strict aseptic precautions with a double needle technique, the chances of
introducing an infection is quite low so it is not justifiable to give broad spectrum antibiotics either
prophylactic or directly in the disc.
Abstract no. 51
RF ABLATION OF OSTEOID OSTEOMAS OF THE SPINE, RESULTS IN 12 PATIENTS
W.R.Obermann, A.H.M.Taminiau, C.H. Pinto
Depts. of Radiology and Orthopaedic Surgery, Leiden University Medical Center, C2S, Albinusdreef 2, 2333
ZA Leiden, Netherlands
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Purpose: To research the application of RF ablation of osteoid osteomas of the spine instead of
surgery.
Material and methods: 12 patients with an osteoid osteoma underwent RF ablation of the lesion. 2
cervical, 1 thoracal, 6 lumbar and 3 sacral lesions. Age of patients mean 20 y (8 - 41), 4 female and
8 male. Size of the lesion mean 7 mm (5 - 14). Location: 4 pedicle, 4 transvers process, 3 pars
interarticularis and 1 arcus. Distance to vital structures: in 6 patients critical with a distance of less
than 2 mm from the border of the osteoid osteoma ( 4x dural sac, 2x nerve root and 1x vertebral
artery).
RF ablation under CT guidance. Approach with the Bonopty drilling system (Radi Medical
Systems, Uppsala, Sweden). RF ablation with the Radionics – RFG 3 C RF – lesion Generator
System, Burlington USA. 8 patients 4 minutes 90 degrees at one location, 3 patients at 2 locations
(6 min.) and 1 patient at 3 locations (10 min.). The mean follow up was 44 month (6 - 84).
Results: 9 patients were cured after the first treatment. In 2 patients a definite second RF ablation
was needed because of residual tumor, 3 and 10 month later. One patient needed surgery of residual
tumor, because of position against a nerve root. There were no complications.
Conclusion: RF ablation of osteoid osteomas of the spine is a good alternative therapy of surgery.
Important is the very precise placement of the needles under CT guidance and to keep away the 5
mm thermo probe at least 5 mm from the vital structures.
Abstract no. 52
ULTRASONOGRAPHIC FOLLOW UP EVALUATION OF ACHILLES TENDINITIS
TREATED WITH ULTRASOUND GUIDED STEROID INJECTIONS INTO A
RETROCALCANEAL BURSA.
Z. Czyrny, R. Smigielski, E. Biernat-Kaluza, M. Bien
Dept. of Diagnostic Imaging, Carolina Medical Center, Warszaw, Poland
Purpose: The purpose of this study was to observe the influence of ultrasound guided steroid
injections into the retrocalcaneal bursa on the inflammatory process of the Achilles tendon and the
bursa.
Materials and Methods: Twenty four patients were qualified for the study. Five patients were
qualified for single steroid injection and nineteen patients for a course of three injections (with two
weeks intervals) into a retrocalcaneal bursa based on clinical and ultrasonographic examination
indicating inflammatory process in the Achilles tendon and retrocalcaneal bursa. All injections were
performed under ultrasonographic control with needle tip visualization within the preachillis bursa.
Patients were followed at least once approximately 4-6 weeks post steroid injection in cases of one
injection. Patients scheduled for a series of three injections were followed every time at the next
injection procedure and approximately 4-6 weeks after the course of injections. Then stayed under
physicians control in case of any reappearing pathologies. The follow-up time is up to 12 months.
Results: All patients had both clinical and diagnostic symptoms of partial or full recovery of the
destructive inflammatory process of the tendon and the bursa. In neither of cases progression of the
inflammatory process and destruction of the tendon structure was observed. One patient had a
recurrence of the tear and a possible reason was the fact that he discontinued the treatment after a
first injection.
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Conclusions: Ultrasound guided steroid injections into a retrocalcaneal bursa are safe and very
effective in the treatment of preachillis bursitis and Achilles tendinitis. Ultrasonography is a
valuable diagnostic method supporting clinical evaluation of the healing process of these entities.
Abstract no. 53
BIOPSY OF MUSCULOSKELETAL LESIONS: THE IMPORTANCE OF COMPARTMENTAL
ANATOMY
C.F. van Dijke, M.B. van der Hoef, A.Z. Ginai, G.P. Krestin
Dept. of Radiology, Erasmus MC University, Rotterdam, The Netherlands
Image guided percutaneous preoperative biopsy of musculoskeletal lesions is indicated in benign
aggressive, malignant and questionable lesions to confirm the clinical diagnosis and accurately
classify the lesion before definitive treatment. Technically, most biopsies seem simple but the
anatomic approach and biopsy technique can make the difference between a successful biopsy and a
catastrophy. The radiologist should be familiar with biologic and radiologic appearances of
musculoskeletal tumors, compartmental anatomy and different biopsy techniques to perform an
adequate biopsy. Collaboration with the surgeon is essential for choosing the right biopsy track
without contaminating tumor free compartments and collaboration with the pathologist is important
for evaluation of the tissue sampling in relation to the differential diagnosis.
Examples op intra- and extracompartmental tumors are shown and the pathways of spread towards
adjacent compartments are discussed. The radiologic approach and sampling methods of soft tissue
masses and intraosseous bone lesions of extremities, vertebrae, pelvis, ribs and sternum are
demonstrated.
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th
Friday, 13th June, 03.00 – 04.40 p.m. – Spine - Session 4a
Chair: A. Mester (HU), E. Llopis (ES)
Abstract no. 54 – Keynote lecture
IMAGING OF THE VERTEBRAL APOPHYSEAL FACET JOINTS:
DIFFERENT SNSA FORMS, MORPHOLOGY AND DIFFERENTIAL DIAGNOSIS OF
INFLAMMATORY VERSUS DEGENERATIVE DISORDERS
A. R. Mester
Dept. of Diagnostic Radiology and Oncotherapy, Faculty of Medicine, Semmelweis University, Budapest
Vertebral facet joint imaging on plain film radiography can be effective in case of new-bone
formation (osteoarthritis OA, psoriatic arthritis PA) if superimposing structures didn’t cover them.
Neither subchondral osteoarthritic lesions, nor erosive inflammation, nor acute synovitis can be
detected.
Bone scan is effective in early ankylosing spondylitis (AS) to detect both, increased perfusion and
reactive ostoblast activity. This type of reaction can be related to early inflammation, and/or
degenerative osteoarthritis, and/or metastatic lesions: all show increased uptake of radiopharmacon. While AS first starts in facet joints, prior to “shiny corner” (Romanus lesion) of
vertebra, and prior to syndesmophytes on the rim of anulus fibrosus, it has a great diagnostic impact
to detect these types of involvement, related to inflammatory ativity. Spatial resolution is poor, only
additional single photon emission computed tomography (SPECT) offers differentiation of vertebral
body lesions and of facet joint involvements.
MRI is very sensitive in detecting direct symptoms of actual inflammatory synovitis in apophyseal
facet joints, but further more details are highly dependent on the base line magnetic field strength
and on other technical factors and parameters of the scanner, influencing spatial resolution. High
resolution MRI can detect intra-articular inflammatory disc-like synovial thickening as well, which
makes it understandable, why facet joint subluxation and spastic reaction causing “segmental
block” occurs in decompensated spondylarthropathy patients.
Indirect MRI symptom of facet OA related segmental instability is subchondral bone marrow
edema adjacent to edplates (Modic I.). Later fatty degeneration (Modic II.) and sclerosis (Modic
III.) will be at the late symptom.
MRI and conventional CT can depict secondary spinal stenosis. It is typical in disc degeneration.
Decreased disc height results in intra-articular incongruent overload of apophyseal facet joints, and
provokes osteoarthritis with reactive new bone formation (osteophytes). Secondary spinal stenosis
is a consequence of both: definitive hypertrophic osteoarthropathy (better detected by CT) and
transient ligamentum flavum thickening (better detected by MRI). Contrast enhanced MRI is
superior to CT in case of postoperative scar formation related thickening.
High resolution CT (HRCT) has the best spatial resolution. This makes it optimal to detect lesions
not seen with any other imaging modalities. In case of HRCT the slice thickness is 1 (maximum 2)
mm, versus 5 – 8 – 10 mm of conventional scanning. Primary data collection of detector system is
optimized by increased number of projections, during tube rotation around the patient. This results
in more information content of raw data, than in case of regular CT. Image reconstruction algorithm
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is using edge-enhancing (high Kernel) filter. The above components together are called “bone
algorithm”.
Degenerative lesions of facet joints show typical appearance of OA, if using HRCT: decreased
joint space (cartilage loss) and subchondral reactions, multifocal sclerotic lesions and pseudo-cystic
lucencies. Often were detected irregularities of cartilage surface. Gas collection (vacuum
symptome) in the facet joints can confirm degenerative lesions.
Inflammation in apophyseal facet joints doesn’t decrease the joint space, but multiple erosions can
occur by HRCT in all types of seronegative spondarthritis (SNSA), similarly to discitis. Deep
erosions were detected in Crohn’s patients. Additional soft tissue calcifications can be seen.
Capsular calcifications in AS are similarly to syndesmophytes, and larger, thicker calcifications,
involving ligamentum flavum in PA, similarly to parasyndesmophytes.
Tuberculotic (TB) inflammation has very specific appearance: destroyed joint. In contrast the
metastatic lesion doesn’t destroy the cartilage, and joint space is preserved.
Metabolic diseases, like diabetes mellitus patients with diffuse idiopathic skeletal hyperostosis
(DISH) have other types of calcifications. Their ligamental calcifications were more spur like with
longer bony bridge formations and often detected in costo-vertebral joints.
Conclusion: Imaging modalities of vertebral apophyseal facet joints have different levels of
sensitivity and of specificity in arthritis and osteoarthritis imaging. In addition, characteristic
morphological features help the differential diagnosis.
Optimal modality to find or to exclude early SNSA is bone scan. Focal inflammation in facet joints
can be seen excellent with MRI. Spinal cord compression related to stenosis can only be evaluated
at MRI. The best spatial resolution of HRCT offers safe detection of erosive lesions and
differentiation of joint space disorders and of subchondral lesions. Osteophytic new bone formation
(hypertrophic osteoarthropathy) and related secondary spinal stenosis can be optimal seen and
measured by HRCT.
Abstract no. 55
ARE ABNORMAL MRI DISC FINDINGS IN 13-YEAR OLD CHILDREN ASSOCIATED WITH
LOW BACK PAIN? AN EPIDEMIOLOGIC STUDY
P. Kjær, J.S. Sørensen, T. Bendix, C. Leboeuf-Yde
The Back Research Center, Backcenter Funen, Ringe and University of Southern Denmark Ringe, DK
Aim: To describe associations between “abnormal” lumbar disc findings and low back pain (LBP)
in 13-year old children.
Methods: In all, 552 13-year old children were invited. Disc changes (signal intensity, nuclear
integrity, height, bulging, protrusion, extrusion, sequestration, annular tears, and high intensity
zones) were identified from MRI. Intra- and inter-examiner reliability was high. LBP was identified
from structured interviews. Significant associations were presented as odds ratios (OR) with 95%
confidence intervals (CI).
Results: The response rate was 80%. LBP was reported within last month/last year by 22%/54%,
and 8% sought care for LBP. Signs of disc degeneration were noted in approximately 1/3 mainly at
L4/S1 levels. Reduced signal intensity and irregular nuclear complex in the upper three lumbar
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discs were significantly associated with LBP within the last month, OR’s between 2.5-3.6 and CI’s
between 1.1 – 15.9, whereas reduced signal and disk protrusion at L5/S1 were associated with
seeking care, OR 2.8 (CI 1.3 – 6.3) and OR 7.7 (CI 1.9 – 30.8) respectively.
Conclusions: Early signs of disc degeneration were present in a fair proportion of children already
at the age of 13 and these were associated with LBP within last month. Protrusions were rare but
strongly associated with seeking care.
Abstract no. 56
MRI FINDINGS IN SCHEUERMANN DISEASE
E. Llopis, V. Higueras, P. Ferrer, Y. Pallardo
Dept. of Radiology, Hospital de la Ribera, Alzira, Spain
E-mail: Ellopis@hospital-Ribera-com
Introduction: Diagnosis, natural history and treatment of Scheuermann disease remain
controversial, due to a wide normal thoracic kyphosis range, atypical forms and high prevalence of
anatomical abnormalities in asymptomatic patients in the thoracic spine.
Purpose: To analyse the spectrum of Scheuermann type changes in thoraco-lumbar MRI studies
and other pathological conditions and to correlate them with clinical presentation.
Material and Methods: 93 thoraco-lumbar MRI with Scheuermann type changes were
retrospectively reviewed, average age 28 years. Patients were referred with low back pain in 84%,
followed by 12% with radicular pain.
The radiographic criteria for Scheuermann disease have been vertebral wedging (5º), disc
narrowing, irregular end-plates and Schmorl nodes in three consecutive vertebrae. Concomitant
thoraco-lumbar anomalies have been assessed: herniated disc, spondylolisis and spinal cord
anomalies.
Results: 1) The area most commonly affected was the thoracic spine in 61.3%, thoraco-lumbar
spine in 20.4% and lumbar changes in 18.2%. 2) Significant disc herniations have been found
(40.8%), 20 patients lumbar, 18 thoracic and 15 patients multilevel. 6 patients had spondylolisis.
Conclusion: 1) Scheuermann sequela can justify recurrent low back pain in young population. 2)
Thoracic and lumbar herniations must be ruled out.
Abstract no. 57
UNFREQUENTLY ENCOUNTERED CAUSES OF LOW BACK PAIN OTHER THAN
HERNIATING DISC:CT FINDINGS
D. Passomenos, G. Katsianakou, P. Makrodimitri, L. Frangopoulou, K. Serveta, E. Karzi
Dept. of Computed Tomography, IKA Hospital (Tzanneion), Athens, Greece
Purpose: Predictive value of computed tomography in depicting pathology other than herniating
disc that causes low back pain.
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Material and Method: We evaluated 1362 patients over a period of 9 months referred to our
department due to low back pain symptomatology. All were healthy individuals with no recent
trauma history. Patients age ranged between 19 to 82 years. Consecutive cuts of 3 mm without
gantry angulation were carried out in the lumbar region. Reformatted images were obtained in
selected cases.
Results: We could locate cases of unilateral spondylolysis (9), posterior limbus vertebra (7),
widedned vertebral recess (6), perineural cysts (8), congenital clefts (4), synovial cysts (4),
conjoined nerve roots (7) and transitional vertebra (11).
Conclusion: A variety of vertebral/neural tissue pathology may generate low back pain. CT may be
the base line diagnostic method in depicting causes of low back pain. CT-myelography may be also
of help in recognizing particular structures.
Abstract no. 58
IMAGING OF THE LUMBAR SPINE IN SCIATICA: MRI REVEAL MORE NONDEGENERATIVE LESIONS
J.S. Sorensen, H.B. Albert, C. Manniche
The Back Research Center, Backcenter Funen, Ringe and University of Southern Denmark, Denmark
Aim: To present the non degenerative MRI-findings from a prospective study of 188 patients
presenting with sciatica.
Methods: Low field MR-imaging was performed in 188 prospective patients referred to the
Backcenter from primary care with sciatica (4-26 weeks duration). All patients with radiating pain
below the knee and pain > 3 on a visual analogous scale, had MRI immediately after the initial
examination.
Results: Intradural extramedullary tumours (two benign swannomas and one tumour not yet
removed) were found in three patients at the age of 29, 42 and 54 years. The tumours measured 12,
18 and 20 mm in transversal diameter and were located at L1, L1/2 and L3/4 levels. Metastasis in
lumbar vertebrals were found in a 52 years old male (spreading from a later diagnosed
adenocarcinoma of the lung). Preerosive inflammations in lumbar vertebral corners and around the
sacroiliacal joints were demonstrated in a 32 years old female, without known spondyloarthropathy.
Conclusion: It is probable that CT had missed the majority of these lesions shown by MRI.
Increasing evidence and guidelines recommend MRI in sciatica. For lack of MR-capacity many xray departments are forced to choose CT, but be aware that a negative CT may be falsely
reassuring.
Abstract no. 59
MR MYELOGRAPHY AS AN ADJUNT TO THE MR EXAMINATION OF THE SPINE
P. Ferrer, L. Martí-Bonmatí, E. Llopis, V. Higueras.
Dept. of Radiology, Clínica Quirón and Hospital de la Ribera, Valencia, Spain
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Introduction: The routinely used diagnostic tests that analyze spinal disorders include plain
radiography, computed tomography, CT-myelography, magnetic resonance (MR), and MRmyelography.
Objective: To analyze the usefulness of MR-myelography as a complementary test to conventional
MR of the spine in patients with clinical symptoms of disco-vertebral degenerative disease.
Material and Methods: Cervical, dorsal and lumbar MR-myelography obtained with 4 planes,
were done immediately after conventional MR. It takes a few seconds. Results were always read by
two investigators. MR myelography was considered relevant if they gave important diagnostic
information (nerve enlargement and nerve root sheath amputation) that were not diagnosed by
conventional MR.
Results: 1022 complete explorations were done. There were 638 cases considered positive in the
MR-myelography examination and 384 cases with a negative MR-myelography. In 16,7% of cases
MR-myelography was considered relevant.
Conclusion: MR-myelography obtained with 4 planes is a fast MR technique that complement the
information obtained with conventional MR of the spine in 42.8% of patients. Due to the high
number of new an relevant diagnosis given by MR-myelography, we consider that MRmyelography should be done in patients with clinical symptoms of disco-vertebral degenerative
disease
Abstract no. 60
REPRODUCIBILITY IN QUANTITATIVE MEASUREMENTS OF DEGENERATE DISC
CHANGES - COMPARISON TO A VISUAL EVALUATION T.S. Jensen, P Kjaer, J.S. Soerensen
The Back Research Center, Back Center Funen and Institute of Sports Science and Clinical Biomechanics,
University of Southern Denmark, Denmark
Purpose: To assess the intra- and inter-observer reproducibility of the quantitative measurements of
degenerate disc changes and to see how these correlate to visual evaluations.
Methods: Two observers blinded to any clinical information, independently evaluated MRI from 50
subjects by measuring disc height and signal intensity. One observer re-evaluated the images of the
same 50 examinations four weeks later.
For reproducibility Limit of Agreement (LOA) with 95% intervals (CI) was used.
To compare the quantitative and visual evaluations, graphical and mathematical models were used.
Results: Using LOA, the average difference for measuring disc height and signal intensity was
between 2% - 7% (SD 9-15%).
The visual evaluation of disc height was without conflicting results with measurements in 76% (CI
62% - 87%).
Box plots of visual evaluation versus disc signal showed a clear differentiation between the visual
gradings when compared to the measured CSF-corrected signal intensities.
Conclusion: Convincing reproducibility in quantitative measurements of disc height and disc signal
was found. The agreement between the visual evaluations and quantitative measurements of
degenerative disc changes was acceptable.
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The results from this study imply that visual evaluations and quantitative measurements are
comparable, which is important for both research and clinical practice.
Abstract no. 61
CONGENITAL SCOLIOSIS: MRI AND MULTISLICE CT EVALUATION
E. Llopis, P. Ferrer, V. Higueras, T. Bas, A.J. Revert
Dept. of Radiology, Hospital de la Ribera, Alzira, Spain
Introduction: Congenital scoliosis is sometimes difficult to interpret with plain films. The rate of
progression depends on many factors, location, type of malformation or concomitant anomalies.
Purpose: To analyse the utility of MRI and reformatted multislice-CT in vertebral malformations.
Materials and Methods: 49 congenital deformities have been reviewed, average age 14 years. All
patients had a MRI to rule out spinal abnormalities with an additional coronal T1WI with MPR and
25 patients a multislice-CT with 3D and MPR.
Results: 1) 9 patients had spinal cord abnormalities (6 patients syringomyelia and
diastematomyelia, tethered cord, lipoma, and Arnold-Chiari in 2 each), 3 multilevel abnormalities.
2) 7 block vertebra, 5 asymmetrical defects of segmentation (unilateral bar), 7 cleft vertebra, 17
hemivertebra (4 fully-segmented, 11 semi-segmented, 2 non-segmented), 1 vertebra agenesia and
12 complex deformities (5 unilateral unsegmented bar with contralateral hemivertebra). 3)
Additional information has been achieved 40/49: defining the bar fusing, degree of segmentation
and ribs contribution.
Conclusion: 1) The entire neural axis should be evaluated. 2) A coronal T1WI adds no significant
additional time in MRI study and the degree of segmentation defect can be assessed. 3) Multislice
CT is limited to complex deformities. To attain maximal information MPR and 3D must be
performed.
Abstract no. 62
COCCYDYNIA: THE UTILITY OF MAGNETIC RESONANCE IMAGING IN ITS
MANAGEMENT
T. R. Palser, G. Bowden and S. J. G. Ostlere
Dept. of Radiology, Nuffield Orthopaedic Centre NHS trust, Oxford, UK
Aim: To evaluate the utility of magnetic resonance imaging in coccydynia.
Patients and Methods: A retrospective search was performed for patients who had had Magnetic
Resonance Imaging (MRI) for the indication of idiopathic coccydynia at our institution over a seven
year period.
Results: There were 79 patients. 56 (70.8%) of these were reported as normal, 7 (8.9%) patients
showed oedema on either side of a coccygeal joint, 12 (15.2%) showed a markedly anteverted
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coccyx. Patients were treated with manipulation, blind or fluoroscopic guided injection. Two of the
patients with oedema underwent fluoroscopy guided steroid injection with good results.
Conclusions: Some guidelines state that imaging should not be done for coccydynia as it will not
change management. This study demonstrates a significant number of patients have abnormal
anteversion of the coccyx a condition that is associated with coccydynia. In addition, focal
peridiscal oedema, a potentially treatable cause of pain, was seen in a significant number of
patients. We therefore propose that patients with resistant coccydynia should be offered imaging,
and that MRI is the technique of choice.
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Scientific presentations – Room 12
th
Friday, 13th June, 08.30 – 10.00 a.m. – Sports Medicine - Session 1b
Chair: C. Faletti (IT), F. Kainberger (AT)
Abstract no. 63
SKELETAL VARIANTS ASSOCIATED WITH CLINICAL SYMPTOMS
J. Brtkova, P. Jirickova
Dept. of Radiology, Faculty Hospital – Charles University, Hradec Kralove, Czech Republic
Purpose: The aim of this presentation is to document the not very commonly appreciated
knowledge, that certain skeletal variants might be associated with clinical symptoms.
Patients and Methods: Four patients with pain in the region of what was reported to be a “normal”
skeletal variant on the plain film underwent examination at our MRI unit: Patient No.1 with a
prominent deltoid muscle insertion, patient No.2 with a dorsal defect of patella, patient No.3 with a
bipartite patella and patient No.4 with os trigonum. T1 and T2 weighted sequences, IR sequences,
contrast enhanced sequences and selected other sequences were performed.
Results: All of the four patients revealed edema at the site of the variant. In addition, patient No.1
revealed an irregular hyperostosis at the deltoid insertion. In patient No.4 the edema was located on
both sides of the gap between os trigonum and the remains of the lateral talar tubercle, as well as at
the posterior margin of distal tibia including the adjoining soft tissues.
Our findings correlate well with the morphology and explanations of the mechanisms of chronic
injury in these sites, given by the literature (i.e. muscle traction and skeletal impingement), as will
be discussed in detail.
Abstract no. 64
SIDESTRAIN: A TEAR OF INTERNAL OBLIQUE MUSCULATURE
D.A. Connell, A. Jambe, T. James
Cabrini Hospital, 183 Wattletree Rd., Malvern, Vicoria 3144, Australia
Purpose: To describe the MR Imaging findings in athletes with sidestrain injury.
Materials and Methods: MR imaging of the abdominal wall was performed in 10 athletes (9 male,
1 female, mean age 28 years) who presented with a sidestrain injury. There were eight acute and
two chronic injuries. Seven injuries occurred in cricket players (6 bowlers), one javelin thrower, a
golfer and a rower. Three normal volunteers also underwent MR evaluation.
Results: The internal oblique muscle lies deep to the external oblique muscle and its fibres run
upwards and forwards from the iliac crest to insert into the undersurface of the lower four ribs and
costal cartilage. All injuries occurred where the muscle inserted onto the rib or costal cartilage.
Four patients had muscle fibres torn from the undersurface of the 11th rib, three from the 10th rib
and two from the 9th rib. Acute tears were characterized by oedema and haemorrhage, with
haematoma often tracking between the internal and external oblique muscles.
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Conclusion: Our study shows that sidestrain is secondary to tearing of the internal oblique muscle
from the undersurface of the lower four ribs and costal cartilage. MR can document these injuries,
identify the site and characterize the severity of injury.
Abstract no. 65
COMPARISON OF ULTRASOUND AND MR IMAGING IN THE ASSESSMENT OF ACUTE
AND HEALING HAMSTRING INJURIES
D.A. Connell, F. Burke, F. Malara, C. Bass, M.E. Schneider-Kolsky
Cabrini Hospital, 183 Wattletree Rd., Malvern, Vicoria 3144, Australia
Purpose: To compare sonography and MR imaging in the assessment of both the acute and healing
phases of hamstring injuries and to identify radiological prognostic factors which can be useful in
establishing the duration of rehabilitation before return to competition.
Materials and Methods: Seventy-two professional football players (male, mean age 24 years)
suspected of an acute hamstring strain were recruited into the study. Twelve players re-injured the
hamstring during the course of the study, leaving sixty players with a single suspected hamstring
injury. All players underwent sonography and MR imaging within three days of the injury, as well
as two and six weeks later. Radiologists were blinded to the alternative scans. The injured muscle
was identified and the following outcome measures assessed at each appointment: injury site within
the muscle unit, length (mm) and crossectional injured area (%), presence of inter-and
intramuscular haematoma, sciatic nerve involvement, presence and type of scar tissue. The
relationship between time to return to competition (days) and all prognostic indicators were
evaluated using univariate linear regression analyses.
Results: At baseline, MRI identified abnormalities in 41/60 (68%) presentations, whereas
sonography found 45/60 (75%). At the two week follow-up, 29/41 (71%) MRI scans were abnormal
and 25/45 (55.5%) using sonography. At six weeks, abnormalities were detected in 16/29 (55%)
players on MRI and in 12/25 (46%) on sonography, although all players except for one had returned
to competition by that time (mean 20 days, range 4-56 days). The intramuscular tendon of the
biceps femoris was the most common injury site identified on both modalities. Our analyses showed
that the longitudinal length of the strain on MRI had a high statistical correlation with time to
recovery (p<0.0001), followed by the crossectional injured area on ultrasound and the presence of
an intermuscular haematoma (p=0.005 and 0.01 respectively).
Conclusion: Both MRI and sonography perform well when characterising hamstring injuries in the
acute presentation. However, sonography becomes less reliable in identifying the injured muscle
during the healing process. The longitudinal length of the strain as measured with MRI within three
days of injury is a strong predictor for the time required to rehabilitate and return to full training and
competition.
Abstract no. 66
THIGH SPLINTS IN A SKELETALLY IMMATURE BOY (CASE REPORT)
S. Van de Perre1,2, F.M. Vanhoenacker1,2, E. Mulier3, A.M. De Schepper2.
1
Department of Radiology and 3Orthopedic Surgery, AZ St-Maarten, Rooienberg, 25, B-2570 Duffel,
Belgium
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2
Department of Radiology, University Hospital Antwerp, Wilrijkstraat, 10, B-2650 Edegem, Belgium
Purpose: To discuss the imaging characteristics of a rare case of thigh splints.
Patient and Methods: A 7-year-old male presented with groin pain and an antalgic gait since two
weeks. There was a history of an accelerated growth. Scintigraphy showed a focal increased uptake
at the medial aspect of the femur. Radiographs, CT scan and MRI revealed a focal periosteal
reaction at the medial aspect of the femur, corresponding to the insertion of the adductor brevis
muscle. On MRI, adjacent medullary edema was seen as well.
The diagnosis of thigh splints was made.
Results and Conclusions:
1. Thigh splints refer to a specific clinical syndrome, due to a chronic avulsion injury at the
adductor insertion sites of the femur.
2. It is usually found in athletic adolescents or military recruits.
3. This case is unusual because thigh splints have never been described in a young non athletic
child. The mechanism in this particular case is not clear, but may result from extreme tension on
the adductor brevis muscle due to an accelerated growth.
4. The presence of bone marrow edema on MRI may suggest that the lesion represents an early
stage of a stress fracture instead of a traction periostitis.
Abstract no. 67
THE REPRODUCIBILITY OF TENDON ULTRASOUND MEASUREMENTS IN HEALTHY
MALE VOLUNTEERS
A.J. Grainger, P.J. O’Connor, K. Smith, S. Morgan, J. Waterton
Dept of Musculoskeletal Radiology, Leeds Teaching Hospitals, Leeds, LS1 3EX, UK.
Aim: To evaluate the inter-visit, inter-observer and intra-observer variation of quantitative tendon
examinations in vivo for a cohort of asymptomatic volunteers.
Patients and Methods: 11 healthy male subjects were recruited. The following tendons were
assessed by ultrasonography: Achilles tendon, Patellar tendon, Triceps tendon, Extensor pollicis
longus, Flexor carpi radialis (FCR), Supraspinatus. For each tendon a quantitative measurement of
tendon size was made at a predefined anatomical location.
Two consultant radiologists, blind to one another’s findings, evaluated each of the tendons
independently. Each tendon was evaluated on two occasions one week apart.
Results: No difference was found to be attributed to variation in tendons between visits. Intraobserver variation was also found to be low, but there was some significant variation between
observers. This variation was more marked with some tendon measures than others. Inter-observer
variation for triceps, FCR and supraspinatus being the most marked.
Conclusion: Inter-observer variation is greater than naturally variation in tendon size when tendon
diameter is assessed with ultrasound. The data allows minimal detectable changes in tendon size to
be calculated.
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Abstract no. 68
JUMPER’S KNEE: DYNAMICAL US EVALUATION DURING WEIGHT BEARING
E. Silvestri, R. Pastorino, S. Parodi, M. Falchi, G. Garlaschi
Dept. of Diagnostic for Images, San Martino Hospital, 16132 Genoa, Italy
Purpose: To evacuate the normal US anatomy of the patellar tendon during weight bearing and to
clarify if WB-US can improve the detection of the pathological findings in patients with jumper’s
knee.
Materials and Methods: Patellar tendons of 15 normal healthy volunteers and 12 patients with
jumper’s knee were examined.
All the US examinations (ATL 5000) were performed using both conventional and weight bearing
approach with a knee flexion of 10°-15°. AP and LL diameters of patellar tendons were measured
on the axial view both in standard and WB conditions. 9 out of 12 patients underwent MR
evaluation.
Results: During WB the patellar tendon showed a round shape with different AP and LL diameters
(ratio LL-AP=1) if compared to the standard US measurements (ratio LL-AP1). This new approach
also significantly reduced anisotropy in the tendon at the attachment level and along the major axis
because of the more parallel orientation of the stressed fibers.
In patients with jumper’s knee, proximal tract appearance wasn’t significantly different from the
tendon examined in standard position. In 9 of the 12 cases of jumper’s knee, WB-US depicted
partial intrasubstance tears of the patellar tendon subsequently confirmed at MR but not so well
demonstrated at conventional US.
Conclusion: WB is a simple device to obtain an US evaluation of the patellar tendon in real
biomechanical conditions and allows a better demonstration of its pathological changes in patients
with jumper’s knee.
Abstract no. 69
ULTRASOUND-GUIDED SCLEROSING OF NEOVESSELS IN TENDINOSIS.
A NEW TREATMENT IN PAINFUL CHRONIC ACHILLES TENDINOSIS AND JUMPERS
KNEE
L. Ohberg, H. Alfredson
Dept. of Diagnostic Radiology, University Hospital of Umeae, 901 85 Umeae, Sweden
Introduction and purpose: Painful chronic Achilles tendinosis and jumpers knee are conditions
known to be difficult to treat. The aetiology and pathogenesis is not known. High resolution
ultrasound with the aid of Colour Doppler is a method to diagnose structural changes and
neovascularization in pathologically changed tendons, and it has been possible to correlate the
occurrence of neovsacularization with painful chronic tendinosis.
Material, Methods and Results: In a pilot study, we describe the effect of ultrasound guided
injections of a sclerosing agent, polidocanol, against neovessels in ten patients with painful chronic
Achilles tendinosis. Eight of ten patients were satisfied with treatment. There was a significantly
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reduced pain during activity and no remaining neovascularization at follow-up, after an average of
two years. Two patients were not satisfied and had remaining neovascularization.
High resolution ultrasound with the aid of Colour Doppler is also a method to diagnose structural
changes and neovessels in the patella tendon in jumpers knee. Also in this group ultrasound guided
injection of policocanol has shown promising results.
Conclusion: Sclerosing of neovessels in patients with painful chronic Achilles tendinosis and
jumpers knee have showed promising short-term clinical results on tendon pain during activity.
Abstract no. 70
INJURIES IN SOCCER: THE DUTCH NATIONAL TEAM
M. Maas, M.C. de Jonge
Dept. of Radiology, Academic Medical Center, Amsterdam, The Netherlands
Soccer is one of the most popular sports worldwide. This popularity is partly reflected in the
number of injuries in soccer, which seem to increase every year. In soccer injuries intrinsic and
extrinsic factors play a role, like e.g. muscle strength, joint stability and pitch conditions. Most
injuries are minor and self-limiting and do not need extensive medical treatment or diagnostic
imaging. Imaging can be required for several reasons e.g. when the clinical findings are doubtful, to
replace arthroscopy or for prognostic reasons. All imaging modalities available can be used but in
general MRI will be the most valuable imaging modality. Basically injuries in soccer can occur
anywhere in the body like in every other sport, like muscle contusions and strains and sprains of
muscles and ligaments. The lower extremities, more specifically the knee and ankle are however the
most injured parts. Apart from more general type of injuries there are also more soccer specific
injuries, like the footballers ankle, footballers fracture of the lower leg or intra-articular knee
pathology. In this presentation we describe these general and more soccer specific type of injuries
and form a Dutch national soccer team of injuries.
Abstract no. 71
PRELIMINARY RESULTS IN VIRTUAL CT ARTHROSCOPY OF KNEE AND SHOULDER
M. Falchi, *F. Livrone, *P. Spagnolo, *E. Silvestri, *G. Garlaschi, G.A. Rollandi
DEA Radiology, *DISM Radiology Inst., San Martino Hospital, *Univesity of Genova, Genova, Italy
Purpose: To evaluate the anatomy of knee and shoulder with virtual arthroscopy and its diagnostic
value compared to artro-CT.
Materials and Methods: We performed 24 knee artro-CT and 18 shoulder artro-CT after
intraarticular injection of iodinated contrast media (n=20) or air (n=22) in patients suspected for
meniscal tears, patellar and femur articular cartilage injury of the knee and labrum tears of the
shoulder. Virtual CT-arthroscopy was obtained using a dedicated reconstruction software and the
resulting images were compared to standard CT axial planes and MPR.
Results: Virtual arthroscopy proved to be a good tool to detect knee articular cartilage damage and
glenoid labrum lesions. Virtual arthroscopy didn’t provide a good assesment of gleno-humeral
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cartilage and menisci because of software issue and poor anatomical access. Real arthroscopy,
performed in 15 cases, confirmed a good agreement.
Conclusions: Virtual CT-arthroscopy supplies a reasonable anatomy of some knee and shoulder
compartments, enabling a good detection of some patologies such as patellar and femural cartilage
defects and glenoid labrum lesions. Orthopedic surgeons founded virtual CT arthroscopy images
more understandable and intuitive rather than axial and MPR CT images.
Some technical aspects are actually liable to be optimized in the short future.
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th
Friday, 13th June, 01.30 – 02.30 p.m. – Osteoporosis/MRI/Cartilage – Session 3b
Chair: J. Adams (UK), G. Glaser (DE)
Abstract no. 72
DIAGNOSTIC IMPACT OF MRI IN DIFFERENTIAL DIAGNOSIS OF VERTEBRAL
OSTEOPOROSIS
S. Forgacs, A.R. Mester, P.N. Kaposi, K. Karlinger, E.K. Mako
Dept. of Diagnostic Radiology, Teaching Hospital Uzsoki, Budapest, Hungary
Purpose of retrospective analysis is MRI differential diagnosis of osteoporotic lesions.
Methods and Materials: Retrospective analysis of 200 spine cases was carried out in respect of
porotic and other bony lesions with similar appearance. Referring diagnoses were spinal pain
syndromes. A low field whole body (0.3 T, Hitachi) scanner was used. Routine SE T1 and SE T2
sequences were completed with STIR and Gd contrast administration in selected complicated cases.
Recently additional opposed phase GRE sequences were used as well.
Results: Increased T2 signal and decreased T1 signal, if diffusely distributed in the vertebral body,
is characteristic (83 %) to recent porotic compressions. In cases of non-compressed vertebral bodies
with diffuse increased T2 signal increase this appearance had a predictive value (67 %) of imminent
compression fracture. Increased T2 signal with decreased T1 signal in adjacent vertebral bodies
accompanied by irregularly of contours and of signal intensity involving the inter-vertebral disc,
and Gd enhancement were symptoms of infection, in particularly spondylo-discitis (specificity 83
%). Opposed phase GRE sequences seems to be optimal in differentiation of metastatic lesions
versus porotic lesions (positive predictive value 88 %).
Conclusion: Spin echo and additional STIR sequence, Gd administration and opposed phase GRE
imaging help the differential diagnosis.
Abstract no. 73
QUANTITATIVE MAGNETIC RESONANCE IMAGING OF THE CALCANEUS IN THE
PREDICTION OF OSTEOPOROTIC SPINE FRACTURES: PRELIMINARY RESULTS AT 3
TESLA
G. Guglielmi, M. Cova, P. Ghedin, A. Accardo, M. Cammisa and R. Toffanin
Dept. of Radiology, Scientific Institute Hospital, San Giovanni Rotondo, Italy
Aim: Comparison of the trabecular bone volume fraction (BVF) and rate constant of the free
induction signal (R2*) derived from MR images of the calcaneus obtained at 3 Tesla with bone
mineral density (BMD) of the spine in the prediction of osteoporotic vertebral fracture status.
Patients and Methods: BVF and R2* were measured in 10 postmenopausal women of varying
spinal bone mineral density (BMD) T scores and vertebral fracture status and in 5 age-matched
controls. MR imaging of the calcaneus was performed on a commercial 3 Tesla whole-body scanner
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using standard acquisition techniques. Bone mineral density of the spine was obtained using
quantitative CT.
Results: Significant differences between both patient groups were observed with BMD and the
MRI-derived data. In particular, R2*, which was lower in the fracture group, appeared to be the
strongest discriminator of vertebral fracture status.
Conclusion: These preliminary data obtained at 3 Tesla suggest that the calcaneus is a suitable site
to predict the osteoporotic fracture status of the spine and that R2* is very sensitive to alterations in
bone quality.
Abstract no. 74
PROJECTION RECONSTRUCTION MR IMAGING OF TRABECULAR BONE
ARCHITECTURE
R. Toffanin1,2, M. Cova3, A. Accardo4, I. Strolka3, F. Vittur1, R. Pozzi Mucelli3
Depts. of Biochemistry1, Biophysics and Macromolecular Chemistry, Radiology3, and PROTOS Research
Institute2, Trieste, Italy DEEI4, University of Trieste, Italy.
Aim: Assess the potential of short-TE projection reconstruction (PR) MR imaging in the
quantitative evaluation of the main structural parameters of trabecular bone.
Methods: The calcaneus of the left leg was examined in ten healthy volunteers. Sagittal high
resolution 3D gradient-echo images were obtained using a 1.5-T clinical scanner equipped with 30mT/m gradients and a two-element phased-array coil. Typically, for the reconstructed PR images
(TE = 2.8 ms, TR = 25 ms) a final matrix of 512 x 512 with a field of view of 10 cm was applied.
Conventional gradient-echo images with the same spatial resolution were also obtained for
comparison. For all images the slice thickness was 0.5 mm. Image analysis was performed using
specific programs written for MATLAB. Standard morphologic parameters such as trabecular bone
volume (TB/TV), trabecular thickness (Tb.Th) and trabecular separation (Tb.Sp) were computed
from the binary images using a modified version of the t3m software.
Results and Discussion: One of the major advantages of the PR method is the possibility of
applying short echo times to minimize the signal phase dispersion due to the high changes in
susceptibility at the bone-marrow interface, which determines an overestimation of the trabecular
dimension. In this work, we demonstrate that the PR method can be applied for a more accurate
characterization of trabecular bone.
Abstract no. 75
SIGNAL INTENSITIES ON T1-WI AND FAT SUPPRESSED T1-W1. WHAT YOU SEE IS NOT
WHAT YOU GET
J. Gielen, A. De Schepper, P. Parizel, X. Wang, J. Weyler
Dept. of Radiology and Epidemiology, University and University Hospital of Antwerp, Belgium
Aim: The incidental observation of high SI of some mass lesions surrounded by normal muscle on
SE T1-WI with FS that are not discriminated on SE T1-WI was the reason to investigate the
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perception mismatch between the 12-bit depth of the DICOM formatted MR-images and the 4-5-bit
depth of the grey scale contrast discrimination ability of the human eye and to study the relative SI
behavior of the tissues on SE T1-WI and SE T1-WI with fat suppression.
Patients and Methods: SI and grey level measurements are carried out in pathologically proven
soft tissue masses not discriminated on SE T1-WI and with high SI on SE T1-WI with FS. Grey
level measurements are also carried out in an in vitro experimental set up.
Results: The three lesions are clearly visible on SE T1-WI with FS. Although not obviously visible,
lesions are of slightly higher SI compared to SI of normal muscle on SE T1-WI. The SI of the nonfatty tissues is not significantly influenced by fat suppression. These findings are corroborated by
the SI changes observed in the in vitro experimental set up. Minor SI differences are made visible in
the three mass lesions if grey scale images are translated in colour maps, because of the higher
discrimination capability of the human eye for colour differences compared with grey scales.
Conclusion: Biophysical limitations of the human eye in the perception of grey scale images will
mask subtle signal intensity differences. The use of colour maps in the presentation of MR images
seems more appropriate and may ameliorate the perception of smaller intensity differences.
Abstract no. 76
VALIDATION AND OPTIMIZATION OF A MULTI-ECHO SEQUENCE FOR T2QUANTITATION OF ARTICULAR CARTILAGE
C. Glaser, T. Mendlik, S. Faber, M. Reiser
Dept. of Clinical Radiology, Ludwig-Maximilians University, Munich, Germany
Introduction: Quantitative evaluation of transverse relaxation times holds promise to detect early
cartilage degeneration in OA. However, there is limited experience of cartilage T2 quantification in
clinical MRI settings and calculated T2 varies depending on the MRI technique used.
Methods and Material: Four multi echo sequence variants ME1-4 were optimized for TE and
resolution (TR/TEmin=3000/13.2ms, resolution=0.47x0.47x3mm3, 8 echoes) and implemented on a
1.5 T magnet: ME1 = standard CPMG, ME2 = ME1 with reduced slice-selection gradient strengths,
ME3 = ME1 with additional spoil gradients, ME4 = ME2 + ME3. T2 values of ROIs were
calculated (monoexponential fit) in 6 Cu2SO4-agarose phantoms and 4 human patellae. Reference
T2 were derived from 8 single echo experiments (SEE).
Results: ME1 and ME2 overestimated T2 by 4 to 46%, ME3 and ME4 underestimated T2 by 13 to
30% compared to SEE data (phantoms). In patellae overestimation of T2 by ME1, ME2 and
underestimation by ME3, ME4 were smaller, ME4 yielded best approximation to SEE.
Discussion: For comparison of calculated T2 relaxation times in cartilage the applied sequence
technique must be considered. Proper T2 quantitation implies minimization of stimulated echos.
Different diffusion coefficients may explain the variable degree of misestimation of T2 in phantoms
versus patellae.
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Abstract no. 77
QUANTITATIVE 3D MR EVALUATION OF AUTOLOGOUS CHONDROCYTE
IMPLANTATION (ACI) IN THE KNEE
C. Glaser, B. Tinns, J.B. Richardson, M. Reiser, I. McCall
Dept. of Clinical Radiology, Ludwig-Maximilians University, München. Germany
Objective: To assess feasibility of 3D volume follow-up in ACI grafts. To evaluate volume and
thickness change in a pilot group of patients.
Material and Methods: 8 patients (21-54y) who underwent ACI for either osteoarthritic or
osteochondral articular cartilage loss in Oswestry/Shropshire. All patients were imaged prior to
surgery and at one year with a FS 3D FLASH (50/11/30) MR sequence in the sagittal plane. After
semi-automatic segmentation (consensus of two readers) 3D reconstruction of the femoral cartilage
plates was performed and cartilage volume, mean thickness and the size of the cartilage bone
interface were calculated.
Results: Despite the presence of some postoperative susceptibility artefacts careful computer
rendering can produce satisfactory volume measurements. The pre-graft volume ranged from
15861 to 22375mm3 (mean 19229), the post graft volume was 15952 to 23044 (mean 19312), the
difference was +11.52% to -11.57% (mean 0.63%). The area of the cartilage bone interface varied
between pre and post surgery by -3.29% to +4.92% (mean 1.89%).
Conclusion: MRI based volumetric assessment of femoral cartilage appear feasible in ACI.
Cartilage volume of the femoral condyles at one year is not significantly altered by the ACI graft
except in the presence of considerable graft overgrowth or graft failure.
95
th
Friday, 13th June, 03.00 – 04.50 p.m. – Soft tissue tumours – Session 4b
Chair: M. Davies (UK), S. Andersson (CH)
Abstract no. 78
IMAGING APPEARANCES OF ACROMIOCLAVICULAR JOINT CYST, CLINICALLY
PRESENTING AS TUMOURS OF THE SHOULDER REGION.
D.W. Tshering Vogel1, L.S. Steinbach2, R Hertel3, J. Bernhard4, E. Stauffer5, S.E Anderson1
1
Dept. of Radiology, University Hospital of Bern, Inselspital, Bern, Schweiz
2
Dept. of Radiology, University of San Francisco,California, San Francisco, USA.
3
Dept. of Othopaedics, University Hospital of Bern, Inselspital, Bern, Schweiz
4
Dept.of Rheumatology, Inselspital, Bern, Schweiz
5
Inst. of Pathology, Murtenstrasse, 31, Inselspital, Bern, Schweiz.
Purpose: To review imaging appearances of acromioclavicular (AC) joint cysts presenting as
tumoral masses.
Materials and Methods: Eight patients presented with tumoral masses of the shoulder region.
There were six males and two females, an age range between 60-83 years and average of 68.7 years.
Imaging was reviewed by consensus with five MR imaging studies (two direct MR arthrography),
one conventional arthrography, one ultrasound and eight radiographs being available. Size of the
lesion, presence of the geyser sign and crystal deposition, status of the rotator cuff, and AC and
shoulder joint degeneration were documented. Clinical and surgical notes were reviewed.
Results: Degenerative changes were present in all AC and shoulder joints. Cyst size ranged from 1
to 3.5 cm. Chondrocalcinose within two cysts was confirmed to be calcium pyrophosphate
deposition with polarized light microscopy. Four patients had either full thickness supraspinatus,
infraspinatus or subscapularis tendon tears. Geyser sign was positive in three. Correlation with
surgery was available in 6 of 8 patients with histology in one.
Conclusion: AC joint cysts may present clinically as a tumour mass. They are commonly
associated with rotator cuff full thickness tears, degenerative joint disease and may be associated
with calcium pyrophosphate deposition.
Abstract no. 79
GRADING AND CHARACTERIZATION OF SOFT TISSUE TUMORS ON MAGNETIC
RESONANCE IMAGING. A PROSPECTIVE STUDY IN 488 PATIENTS.
J. Gielen, A. De Schepper, P. Parizel, J. Weyler, X. Wang, F. Vanhoenacker
Dept. of Radiology and Epidemiology, University and University Hospital of Antwerp, Belgium
Aim: The purpose of this study is to evaluate prospectively the accuracy of MRI in grading and
characterization of soft tissue tumors and pseudotumors.
96
Patients and Methods: The material consists of 488 consecutive untreated and pathologically
proven soft tissue tumors (STT) or tumorlike conditions.
Grading, definition of phenotype and more specific (histological) diagnosis are defined using MRparameters described in literature and based on personal experience of the authors.
Comparison between MR findings and final pathological diagnosis is statistically worked out with
calculation of predictive value (positive and negative), sensitivity, specificity.
Results: 110 patients presented with a malignant SST, 378 with a benign one.
Grading results: 311 true negative, 8 false negative, 67 false positive and 102 true positive cases.
Characterization results: A correct histological diagnosis is made in 301 (62%) of cases (260 benign
and 41 malignant).
Statistical workup in %:
Grading:
spec 82, sens 93, PPV 60, NPV 97
Phenotype Overall:
Phenotype Benign:
Phenotype Malignant:
Phenotype Fat:
sens 84, PPV 90
Phenotype Pseudotumors: sens 74, PPV 87
Conclusions: Preoperative grading and characterization of STT by MRI is gaining importance
because of diagnosis dependent therapeutic approach. Our prospective study proves that MRI
reliably identifies malignancy. However only in a minority of malignant tumors the MRI
appearance is tissue-specific. The high negative predictive value will avoid misdiagnosis of a
malignant tumor as a benign one and inappropriate treatment as a consequence. STT are confidently
differentiated from pseudotumors, benign STT are accurately categorized in phenotypes and a
specific MR diagnosis was made in 70% of them. If the MRI appearance is benign but non-specific,
we advocate to perform a biopsy in order to lower the number of false negatives.
As a consequence MRI will be a most useful tool in grading and characterization i.e. definition of
phenotype and histological diagnosis of STT.
Abstract no. 80
THE STUDY OF SOFT TISSUE MASSES USING CONTRAST MEDIUM IN ULTRASOUND:
PRELIMINARY EXPERIENCE WITH A NEW CONTRAST MEDIUM AND DEDICATED
MACHINE
A. De Marchi, L.Verga, P.De Petro, S.Pozza, C. Faletti
Dept. of Radiology, Inst. De Radiologia CTO-CRF-M. Adelaide, Torino, Italy
Purpose: To identify the role of contrast ultrasound (CU) using a new contrast medium (c.m.) in
soft tissue masses.
Materials and methods: A total of 35 patients with mixed soft tissue masses were examined; 3
were suspected of having a relapse. Firstly, all patients underwent routine US, followed by a first
generation contrast medium study.
A new second generation contrast medium (SonoVue, Bracco) and dedicated unit for musculoskeletal extremity evaluation, were then used and the results compared to the previous ones. All
patients had MRI whith contrast medium, as well as histological examination.
97
Results: 17 patients had malignant and 18 benign lesions. Traditional US with color and power
doppler and MRI with c.m. demonstrated the enhancement of the lesions. The new c.m. better
defined detection of flow in such smaller vessels increasing considerably the clinical utility of US
so evidencing reduction in vascularity, for instance, in ischemic or infarcted tissues or increasing in
vascularity, for instance, in tumor angiogenesis.
Conclusions: On the basis of our previous experience, studying the importance of vascularization
in soft tissue masses and its distribution, the use of this new specific c.m. and a dedicated unit with
low mechanical index, provided useful diagnostic information, not only as to the nature of the
masses, but also relapse rate.
Abstact no. 81
MERKEL CELL CARCINOMA, A RARE AGGRESSIVE CUTANEOUS NEUROENDOCRINE
TUMOR: REVIEW OF MR AND IMAGING FINDINGS IN THIRTEEN PATIENTS AND
LITERATURE REVIEW.
S.E. Anderson*, K. Beer, A. Banic, E. Stauffer, L.S. Steinbach, M. Martin, E. Friedrich, M.
Weissmeyer, R. Greiner.
Dept. of Radiology, University Hospital of Bern, CH-3010 Bern, Switzerland
Purpose: To determine imaging characteristics of merkel cell carcinoma, with emphasis on MR
imaging and histologic correlation.
Method: Patient demographics, clinical notes and imaging of 13 patients from a single institution
were retrospectively reviewed by two musculoskeletal radiologists by consensus. Imaging studies
included MRI (n=13), CT (n=39), radiograph (n=54), ultrasound (n=6), somatostatin scintigraphy
(n=1) and PET (n=2). Scans were reviewed for lesion location and intrinsic characteristics.
Histopathology was correlated with imaging by the primary author and pathologists.
Results: There were three females and ten males with an age range of 48 to 87 years, mean of 70.7
years. MR imaging showed Indian file-like soft tissue masses with reticular stranding (n=5); large
lymph node masses with retained internodal fat (n=5); nodal necrosis (n=1); perifascial and
intramuscular metastases (n=2). Distant metastases involved: bone (n=2), liver (n=1) and lung
(n=1). Histology confirmed the lymphatic nature of the soft tissue metastases.
Conclusion: Merkel cell carcinoma of the skin may present at imaging with multiple Indian filelike soft tissue lymphatic metastases and large lymph node masses with retained internodal fat.
Abstract no. 82
IMAGING SPECTRUM OF LIPOMATOUS TUMOURS
T. Muthukumar
Dept. of Radiology, Aberdeen Royal Infirmary, Aberdeen, UK
98
Aim: Describe imaging features of musculoskeletal lipomatous tumours and elucidate
characteristics enabling one to differentiate between benign and malignant lesions; as well as
differentiate between lipomatous variant tumours.
Method: The surgical and radiology database at Aberdeen Royal Infirmary was reviewed from
1997 to 2002 for lipomatous tumours. Imaging for review was available in 69 patients with
histologically proven diagnosis.
Result: The lipomatous tumours comprised of superficial and deep lipomas; heterotopic lipomas –
intramuscular, intermuscular, discrete lipoma of tendon sheath; infiltrating lipomas – diffuse
lipomatosis, shoulder girdle lipomatosis; parosteal lipoma; fibrolipoma; angiolipoma; pleomorphic
lipoma; hibernoma; and liposarcoma. There were 65 MR imaging studies, 13 CT examinations, 5
ultrasound and 5 angiographic studies.
Conclusion: MR and CT images of lipomatous masses are usually characteristic to suggest the
diagnosis. Ultrasound is usually nonspecific. Angiography results depends upon the relative
vascularity of the lesion, rather than tumour type. While the histological variants cannot be
convincingly predicted, correlation between various radiologic modalities may provide sufficient
indication in certain lesions such as angiolipomas. Although of limited value in characterizing
liposarcomas, MR imaging is the best modality to demonstrate the pathologic anatomy, essential for
preoperative planning and post operative followup.
Abstract no. 83
INTRAMUSCULAR LIPOSARCOMA IN THE FOREARM: A RARE CASE REPORT
A. Aurangabadkar, N. Emms, B. Bolton-Maggs, M.J. Pinto
Dept. of Orthopaedics with contributions from Depts. of Pathology and Radiology, Whiston Hospital,
Prescot, Merseyside, UK
Introduction: Intramuscular liposarcoma is a rare malignant tumour, most commonly seen in the
thigh and shoulder. No other case of intramuscular liposarcoma in forearm has been reported in the
literature.
Case report: A 72 year old lady presented with a lump on the flexor aspect of left forearm. It was
slowly growing over few months. It was a well demarcated, soft, nodular mass of 2x3 cm, not
attached to the skin. Clinically it was within the flexor musculature.
Plain radiograph showed a soft tissue mass, not attached to the bone. MRI scan revealed a well
defined spindle shaped lesion in the left brachioradialis muscle. High signal on T2W images with
central low signal area. T1W images were unhelpful.
The lesion was excised. Histology revealed a dedifferentiated liposarcoma.
Discussion: Dedifferentiated liposarcoma is a very rare tumour of aggressive nature. It spreads
early to lungs. The most common site of extra pulmonary spread being retro peritoneum.
Conclusion: This report stresses the importance of investigating enlarging, painless soft tissue
masses in upper extremity. MRI scanning is considered the best mode of investigation but is not
specific. We believe that this is the first dedifferentiated intramuscular liposarcoma of forearm to be
reported.
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Abstract no. 84
ANCIENT SCHWANNOMA OF THE SENSORY BRANCH OF THE MEDIAN NERVE (CASE
REPORT)
R.B.Comert1, G. Leblebicioglu 2, U. Aydingoz1, G. Gedikoglu3
Dept. of Radiology1, Orthopaedics and Traumatology2, and Pathology3, Hacettepe University Faculty of
medicine, Ankara, Turkey
Purpose: To report a unique case of an ancient schwannoma of the median nerve.
Patients and methods: A 45-year-old male presented with a 3-month history of numbness and
midpalmar swelling at his left hand. Physical examination revealed a 2x2x4 centimeter midpalmar
mass and loss of sensation at the opposing surfaces of third and fourth fingers. Preoperative MR
imaging was performed.
Results: MR imaging showed a tumour that was predominantly slightly hyperintense on T1- and
heterogeneously hyperintense on T2-weighted and fat supressed images in comparison with
muscles. In surgery, the lesion was found to be located at the origin of the third common digital
nerve from the median nerve, therefore affecting only a sensory branch of the median nerve.
Marginal excision conducted to a histopathologic diagnosis of ancient schwannoma.
Conclusions: Ancient schwannomas are histologically characterised by features of severe
degeneration. Only scattered papers could be found in the literature describing the imaging findings
of these rare tumours. Despite they are usually tumours of long duration, our patient had a 3-month
history. Our case is the second at the median nerve, though the first involving a sensory branch of
the median nerve, based on a comprehensive search in the world literature.
Abstract no. 85
SOLITARY CUTANEOUS ANCIENT SCHWANNOMA OF THE ELBOW (CASE REPORT)
R.B. Comert1, G. Leblebicioglu2, G. Gedikglu3, U. Aydingoz1
Depts. of Radiology1, Orthopaedics and Traumatology2, and Pathology3, Hacettepe University Faculty of
Medicine, Ankara, Turkey
Purpose : To report the first case of a solitary cutaneous schwannoma, as well as the first case of an
ancient schwannoma at the elbow in the medical literature.
Patients and Methods: A 55-year-old male presented with a 10-year history of a slowly growing,
bulging mass on his left elbow. MR imaging was performed to evaluate the precise extent of the
lesion.
Results: MR imaging demonstrated a smooth-contoured elbow mass, displacing the pronator teres
muscle and protruding through the skin. The tumour was predominantly close in signal intensity to
muscle on T1- and heterogeneous on T2-weighted images. After contrast administration, peripheral
part of the tumour showed marked enhancement, while central portions did not enhance. The mass
was totally excised and histologic diagnosis was cutaneous schwannoma with degenerative features
(ancient schwannoma).
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Conclusion: Cutaneous localization is unusual for schwannoma and ancient schwannoma is an
uncommon variant of benign schwannoma which does not have well-established imaging features
and has histologically often been misinterpreted as sarcoma, due to the frequent association of
cytologic atypia with degenerative changes, resulting in unnecessary treatment and follow-up. In
fact, these changes do not imply any malignant transformation and marginal excision is the
treatment of choice to spare the surrounding nerves.
Abstract no. 86
VASCULAR MALFORMATION IN THE INFRAPATELLAR (HOFFA’S) FAT PAD (CASE
REPORT)
R.B. Comert1, U. Aydingoz1, A.O. Atay2, G. Gedikoglu3, N.M. Doral2
Depts. of Radiology1, Orthopaedics and Traumatology2, and Pathology3, Hacettepe University Faculty of
medicine, Ankara, Turkey
Purpose: To present a unique case of a vascular malformation in an extremely rare location.
Patients and Methods: A 16-year-old girl presented with pain and swelling of her right knee for
two years. MR imaging was performed to reveal the cause of her complaints.
Results: MR imaging disclosed a poorly marginated, lobulated mass at the infrapatellar fat pad. The
lesion was isointense on T1- and hyperintense on proton-density and fat-saturated images, relative
to muscle. Arthroscopic removal of the lesion led to a histopathologic diagnosis of arteriovenous
malformation.
Conclusions: Hemangiomas and vascular malformations are endothelial abnormalities that can
cause considerable morbidity and mortality. There have been eight cases of synovial hemangioma
of Hoffa’s fat pad in the literature. However, none of the subgroups of vascular malformations that
exclusively involves Hoffa’s fat pad has been previously reported in the English-language literature.
Although high-flow malformations are diagnosed on MR images by the presence of dilated vessels,
which are identified as signal flow voids, the lesion in our case lacked signal voids, despite
subsequent histopathologic diagnosis of arteriovenous malformation. Therefore, our case illustrates
that the lack of signal flow voids may not totally exclude the possibility of a high-flow vascular
malformation.
Abstract no. 87
WATER-LILY SIGN ON MR IMAGING OF PRIMARY INTRAMUSCULAR HYDATIDOSIS
OF SARTORIUS MUSCLE (CASE REPORT)
R.B. Comert1, U. Aydingoz1, A. Ucaner2, M. Arikan2
Dept. of Radiology1, Hacettepe University Faculty of Medicine, Ankara, Turkey
Dept. of Orthopedic Surgery, Ankara Oncology Hospital, Ankara, Turkey
Purpose: To document the pathognomonic water-lily sign in a case with intramuscular hydatid
disease.
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Patients and Methods: A 35-year-old woman presented with a one-year history of painless mass in
her distal left thigh. MR imaging was performed for preoperative diagnosis and surgical planning.
Results: MR imaging showed a cystic mass within the sartorius muscle, containing multiple cysts
and collapsed cyst membrane in the inferior portion of the mother cyst, suggestive of the water-lily
sign of hydatidosis. The cystic mass was subsequently resected and histopathologic diagnosis was
hydatid disease.
Conclusion: Primary hydatidosis of the skeletal muscle is extremely rare and can cause a variety of
diagnostic problems. Ours is the third case involving exclusively sartorius muscle in the Englishlanguage literature. Although the water-lily sign was established as a pathognomonic sign in hepatic
and pulmonary hydatid disease and also described in cerebral and orbital hydatid cysts, it has not
been previously reported in an intramuscular hydatid cyst. This sign may help the accurate preoperative diagnosis of this disease to avoid percutaneous needle or open biopsy and inproper
handling during surgery, as these procedures can lead to inadvertent cyst rupture with the
consequent risks of anaphylaxis and dissemination to other organs.
Abstract no. 88
MR IMAGING OF CHRONIC EXPANDING HEMATOMA
J.C. Vilanova*, C. Sánchez**, J. Barceló*, R. Pérez-Andrés**, J. Mota***, M. Villalón*,
*Clínica Girona. Girona. **Hospital Universitari “Germans Trias i Pujol”. Badalona. ***Clínica Corachan.
Barcelona. Spain
Purpose: Describe the MR features of chronic expanding hematoma
Material and Methods: We review three patients with chronic expanding hemtoma occurring in
the musculoskeletal system.
Results: The lesions were located in the subcutaneous perifascial tissue of the tight in two cases and
in the perifascial-intramuscular tissue of the right tight in the third case. In two cases an injury to
the affected side had been noted 2 years and 5 years beforehand respectively. The other patient
refereed surgery for a benign neoplasm 20 years previously. Clinically a neoplasm was suspected.
MRI showed huge soft tisse masses with heterogeneous signal intensity on both T1- and T2weighted images with a peripheral thick rim of low intensity with a villous appearance. These
findings correlated with central fluid with blood and a collageneous fibrous villous capsular tissue.
Conclusion: The MR findings of chronic expanding hematoma are to be considered characteristic
when affecting patients with previous history of trauma or surgery.
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th
Saturday, 14th June, 08.30 – 10.00 a.m. – Spine and bone marrow - Session 5a
Chair: A. Mester (HU), A. Bauer (DE)
Abstract no. 89
COMPARISON OF CLINICAL AND RADIOLOGICAL FINDINGS OF 89 OPERATED
PATIENTS WITH TBC AND PYOGENIC SPONDYLITIS IN LATVIA
S. Dzelzite1, G. Maurins2, A. Platkajis3, M. Epermane4
1
RSU Institute of Radiology, 2State Centre of Tuberculosis, 3RSU Institute of Radiology and 4Hospital of
Traumatology and Orthopaedics, Riga, Latvia
Purpose: To perform retrospective analysis of findings of 89 operated patients with histologicaly
proven spondylodiscitis of TBC and pyogenic origin.
Materials and Methods: Histories, results of laboratory tests (including intraoperative histological,
bacteriological results) and radiological findings (CT, MRI) of patients were compared statisticaly
between two groups with proven spondylodiscitis.
Results: 30 cases were of tuberculosis origin, 69 cases had the pyogenic infection. All patients with
TBC spondylitis had previous proven infection of tuberculosis in other systems. Radiological
findings in cases of TBC origin: involvement of more than two vertebrae(17), deformation of
spine(22), formation of paravertebral, epidural abscesses(15), and monovertebral involvement(3).
In all cases of pyogenic spondylodiscitis we found classical radiological appearance of infection –
destruction of the intervertebral disc and nearby vertebral bodies, but the causes were different. In
most of the cases(29) there was a dissemination of pyogenic infection from the other localization,
the postoperative infection direct to osseous spine(21) or other abdominal and pelvic interventional
procedures(11). No potential cause(8). Large bone destruction was common finding after
discectomy.
Conclusion: Monovertebral involvement is finding of tuberculosis spondylitis. TBC infection of
spine is secondary. Other radiological findings are non specific.
Abstract no. 90
MRI OF CERVICAL SPINE METASTASES - A REVIEW OF THE FINDINGS IN 30
PATIENTS
M. Ewan Anderson, J. Teh, P. MacAlinden
Dept. of Radiology, Nuffield Orthopaedic Centre, Oxford, UK
Introduction: The vast majority of spinal metastases involve the lumbar and throracic spine. The
cervical spine is much less frequently involved.
Aim: To review the spectrum of plain film and MRI findings in 30 patients with cervical spine
metastases. To compare the sensitivity of plain films using MRI as the gold standard.
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Method: Retrospective review was undertaken by 2 musculoskeletal radiologists
Lesions classified according to position (anterior, middle or posterior), presence of cord
compression and presence of pathological fracture.
Results: Most lesions involve the anterior and middle columns of the spine. Cord compression was
present in 30%. Pathological fracture was present in 16%, with 3 Hangman's fractures. MRI was
poor at demonstrating fractures. Plain radiographs had a sensitivity of 50%.
Conclusion: There is a wide spectrum of presentation of cervical spine metastases. MRI
demonstrates extent of disease very well but may miss pathological fractures.
Abstract no. 91
DIAGNOSTIC ACCURACY OF A DW-SSFP SEQUENCE FOR DIFFERENTIATING BENIGN
AND NEOPLASTIC FRACTURES
A. Baur, A. Stäbler, C. Pellengahr, M. Reiser
Dept. of Diagnostic Radiology, University of Munich, Munich-Germany
Purpose: To evaluate the diagnostic accuracy of a diffusion-weighted steady-state free precession
(SSFP) sequence for the differentiation of acute benign osteoporotic and neoplastic vertebral
compression fractures.
Methods: 85 patients with 102 vertebral compression fractures were examined (Siemens, Vision).
The sequence protocol included T1-weighted SE, STIR and a diffusion-weighted SSFP sequence.
The SSFP images were evaluated qualitatively on a 5-grade scale from strongly hypointense to
strongly hyperintense. Quantitative analysis was performed with region of interest measurements.
Results: Qualitative analysis of the osteoporotic fractures (n=60) resulted in strong hypointensity in
14 fractures, mild hypointensity in 28 fractures, isointensity in 14 fractures and mild hyperintensity
in 4 fractures. In the tumor group (n=42) 22 cases showed mild hyperintensity and 20 fractures
strong hyperintensity. Thus, “hyperintensity” in a vertebral fracture on a SSFP sequence provided a
sensitivity of 100% and a specificity of 93% (PPV=91%, NPV=100%). The mean values of the
bone marrow ratio for the osteoporotic fractures differed significantly –0.32 from the tumor group
(+ 2.07, p<0.001).
Conclusion: The SSFP sequence provided a high accuracy in the differentiation of benign
osteoporotic and neoplastic vertebral compression fractures.
Abstract no. 92
DIFFUSION WEIGHTED IMAGING (DWI) OF BONE MARROW LESIONS
A. Baur
Dept. of Clinical Radiology, University of Munich, München, Germany
Purpose: To evaluate the ADC values of different bone marrow lesions with a diffusion-weighted
Haste method.
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Methods: 23 patients were examined with surface-array coils on a 1.5 Tesla scanner with T1weighted spin echo (SE), short-tau inversion recovery (STIR) and diffusion-weighted half-Fourier
acquired single-shot turbo-spin echo (HASTE) sequences with diffusion strengths yielding four bvalues (50-750 seconds/mm2). Quantitative analysis was performed with region of interest
measurements (ROI) and calculation of the ADC´s.
Results: On routine T1-weighted SE and STIR images bone marrow edema and metastases showed
the same signal alteration with high signal intensity on STIR and low signal intensity on T1weighted SE images. DWI of one slice can be acquired in 12 seconds (10 AC), therefore motion
artifacts are limited. Image quality was adequate in all patients. Edema as well as tumor showed
signal loss on DWI. ADC values of benign edema were significantly higher (mean value 1,37 x 10 3 mm2/sec) than the ADC´s of neoplastic bone marrow involvement indicating higher diffusion of
water protons in edema (mean value 0,95 x 10-3 mm2/sec, p<0.01).
Conclusion: DWI has the potential for increasing the specificity of musculoskeletal lesions
especially for differentiating bone marrow edema from metastatic infiltration of the spine.
Abstract no. 93
FEASIBILITY OF DIFFUSION WEIGHTED IMAGING IN PEDIATRIC
MUSCOLOSKELETAL DISEASES.
S.F. Carbone, C. Fonda, *V. Ricci
Department of Pediatric Radiology, Meyer Children’s Hospital, Firenze, Italy
*Radiology Unit, St. Joseph Hospital, Empoli, Italy
Purpose: Aim of this work is to assess feasibility of DWI and review its application in pediatric
muscoloskeletal disease.
Patients and Methods: We studied 15 patients (range 6 months – 14 years old), using a single-shot
echo-planar (SS-EPI) sequence with a diffusion gradient (b-value=0,300,600,800) for DWI.
Controlateral body segments, when possible, and five normal knees examined with the same SSEPI-DWI were used as reference. Apparent coefficient of diffusion (ADC) and signal to noise ratio
(SNR) was calculated.
Results: ADC of non-pathologic bone segments was included between 0.36 and 0,75 x10-3
mm2/sec. In medullary edema and osteomyelitis ADC was up to 1 x10-3 mm2/sec; in vascular
lesions, such as angiomas and an aneurysmatic cyst ADC was included between 1,91 and 2,42 x10-3
mm2/sec. The increase in b-value caused reduction of SNR and of perfusion influence on ADC.
Magnetic susceptibility artefacts were present in half of cases.
Conclusion: DW-MRI may be a fast non-invasive technique for studying bone lesions. Further
studies need to assess the availability to reduce artefacts.
Abstract no. 94
WHOLE-BODY MRI FOR DETECTION SKELETAL METASTASES IN CANCER PATIENTS
AND IN BENIGN PATHOLOGY OF BONES
J.C. Vilanova*, J. Barceló*, M Villalón*, M.D. Figueras**, J. Tarradas**,
105
*Resonancia Magnética. Clínica Girona, Girona. **Hospital Palamós, Palamós, Spain
E-mail: rmgirona.comg.es
Purpose: Presentation of our preliminary experience with a WB-MRI technique with an automatic
moving table as a screening tool for metastases in patients with cancer, and possible application also
in benign pathology of bone with multiple or systemic location.
Materials and Methods: Fast WB-MRI was performed in 24 patients with histologically known
malignant tumors and clinical suspicion of bone lesions. The automatically moving table was used
for fast T1-SE and STIR sequences covering nearly the whole skeleton. The total time of
acquisition was only 18 minutes. We compared WB-MRI and bone scintigraphy findings.
Metastatic lesions were confirmed by follow-up over 6 months or biopsy.
We accomplished the same protocol in 3 patients with benign pathology of bones.
Results: WB-MRI was superior to bone scintigraphy in predicting lesions dignity with a sensitivity
of 100% (bone scintigraphy: 78%), a specificity of 93% (scintigraphy: 67%) and an accuracy of
96% (scintigraphy: 71%). WB-MRI showed additional metastases in extra-skeletal regions of the
body.
Conclusion: WB-MRI with automatic moving table technique is an effective method for evaluating
the entire skeleton in patients with suspected bone metastases. WB-MRI has significant higher
sensitivity and specificity to scintigraphy in the detection of bones metastases, and also can detect
extra-skeletal lesions. This technique is also useful to evaluate benign pathology of bones with
possible multiple locations.
Abstract no. 95
PRIMARY LYMPHOMA OF BONE: IMAGING FINDINGS AND CONTRIBUTION OF MRI
TO THE DIAGNOSIS
Al. Garcia, X. Tomás-Batlle, J. Pomés, C. Mallofré, R. Zuñiga
Dept. of Diagnostic Radiology, Hospital Clinic, Barcelona, Spain
Purpose: The aim of this study is to review the imaging appearances of primary lymphoma of bone
(PLB) and to show the various imaging patterns, particularly those of magnetic resonance imaging
(MRI), suggesting the diagnosis.
Patients and Methods: Five histologically proven cases of PLB and one primary multifocal
osseous lymphoma (PMOL) with 6 lesions, were studied by radiographs, bone scintigraphy,
computed tomography (CT) and MRI. Signal intensity on proton-density (PD) and T2-weighted
MRI were correlated with histopathologic assessment of tumoral fibrosis in 4 lesions.
Results: Normal radiographs, permeative, lytic and mixed pattern, single layer of periosteal
reaction, fracture, sequestrum, soft-tissue mass without or with large areas of cortical breakthrough,
and spread across joints were findings observed. MRI were more sensitive, showing marrow
extension, spread across joints and extra-osseous soft-tissue masses. The four cases studied by PD
and T2-weighted MRI displayed low signal intensity to fat and histology showed moderate to large
amounts of fibrosis.
Conclusions: PLB display non-specific images, but a combination of findings can suggest the
diagnosis, particularly when MRI shows soft-tissue mass abnormalities without large areas of
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cortical bone destruction, low signal intensity to fat on PD and T2-weighted MRI, and normal
findings on radiography are observed.
Abstract no. 96
DETECTION OF OSSEOUS METASTASES USING MULTI-SLICE-CT
A. Wieser, A. Baur, M. Reiser
Department of Clinical Radiology, University of Munich, Klinikum Großhadern, München, Germany
Purpose: The aim of the study was to evaluate the diagnostic accuracy of 16-Row-Multi-Slice-CT
in detecting osteolytic and osteosclerotic metastases of the spine and the pelvic in patients suffering
from malignant tumors in comparison with MRI.
Patients and Methods: Imaging studies of 23 patients with histologically assured carcinoma of the
mamma, the prostate, the lung and the kidney were reviewed. The CT-images were aquired on a 16Row-Multi-Slice-CT and displayed in a sharp bone kernel. Using a 1.5 Tesla-MRI, three sequences
were applied: a STIR-sequence, a T1-weighted SE-sequence with and without contrast medium.
Two experienced radiologists evaluated the examinations.
Results: According to the advantage of the CT in displaying bone structures, all osteosclerotic
metastases were detected in CT as well as in MRI. Due to the direct visualisation of bone marrow of
early metastases without massive bone destruction, there was a difference between CT and MRI
detecting osteolytic metastases. About 20% of the early osteolytic metastases couldn´t be identified
with CT.
Conclusion: This study shows the MRI slightly superior to MSCT in detecting osteolytic
metastases, because of the better visualisation of bone marrow of early metastases without massive
bone destruction.
Abstract no. 97
PATHOLOGICAL-RADIOLOGICAL CORRELATIONS IN OSTEONECROSIS (ON) AND
BONE MARROW OEDEMA SYNDROME (BMES)
K. Karlinger, L. Nemeth, S. Forgacs, P.N. Kaposi, K. Kollo, A.R. Mester
Depts. of Diagnostic Radiology, Oncotherapy and Orthopaedic Surgery, Semmelweis University, Faculty of
Medicine, Budapest
MRI Centre of National Institute of Rheumatology and Oncotherapy, Budapest, Hungary
Purpose: The aim of the study was to analyse the morphological similarities and differences of
osteonecrosis (ON) and bone marrow oedema syndrome (BMES) in respect of pathological
correlations.
Methods and study design: Plain film radiography (PFR), MRI, high resolution CT (HRCT) and
bone scan (included SPECT quantitative assessment of bone scintigraphy) of femur, knee, shoulder
and ankle studies were compared in context of clinical history and follow up.
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Results: Different forms of BMES and/or transient epiphyseal lesions versus spontaneous
osteonecrosis, avascular necrosis (AVN) i.e. aseptic necrosis, posttraumatic osteonecrosis, nontraumatic osteonecrosis, bone marrow infarction (decompression i.e. disbaric osteoarthropathy
(Caisson disease), initial forms of neurogenic osteoarthropathy, osteonecrosis of the renal
transplantation (chronic haemodyalisis patients), systemic lupus erythematosus, patients with a
history of corticosteroid therapy and of coagulopathy, inflammatory bowel disease were
differentiated by multimodality approach and clinical follow up. Oedema related to Sudeck and
algodystrophy, related to initial forms of malignancies and to inflammations, to porotic and to
microtrabecular fracture (bone bruise) or to insufficiency (stress) fracture were discriminated from
spontaneous osteonecrosis and from BMES.
Conclusion: Bone marrow oedemas related to idiopathic and secondary osteonecrosis are different
entities versus BMES and of osteochondritis dissecans and of degenerative osteoarthritis due to
differences in the pathogenetic mechanism.
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th
Saturday, 14th June, 10.30 – 12.00 a.m. – Arthritis, - Session 6a
Chair: J. Freyschmidt (DE), J. Gelineck (DK)
EXTRAAXIAL MANIFESTATIONS OF PAO (SAPHO) – A CHALLENGE FOR THE
MUSCULOSKELETAL RADIOLOGIST
J. Freyschmidt, P. Freyschmidt-Paul, A. Sternberg
Klinik für Radiologische Diagnostik und Nuklearmedizin, Bremen, Germany
Pustulotic arthroosteitis (PAO) and SAPHO-Syndrome (S = syndrome or synovitis, A = acne, P
= pustulosis, H = hyperostosis, O = osteitis) are the most commonly used synonyms for a sequence
of symptoms whose essential features are pustulosis palmoplantaris (PPP), sternocostoclavicular
hyperostosis (SCCH) and a mixture of proliverative and destructive changes of the axial and
appendicular skeleton.
We prefer the term PAO, because it best reflects the cardinal features of the disease. The acronym
SAPHO may be more attractive for the ear (an earwig), but it is likewise less exact: acne-associated
skeletal changes are different from those that are associated with PPP, and hyperostosis is usually
the result of chronic aseptic osteitis. Moreover: We believe principally that disease entities are
always best described by a name that directly reflects their cardinal pathologic features.
PAO is one of the most spectacular entities of the group of SKIBO- (SKIN-BONE)– diseases that
affect the skin as well as the skeleton.
Because of their interdisciplinary features especially the radiologist is confronted with SKIBOdiseases and he should be aware of misdiagnosing. He is challenged to look specifically for
symptoms usually diagnosed by other disciplines (i.e. dermatology, othopedics, rheumatology) and
to make the diagnosis only by synoptic considerations.
PAO should be classified under seronegative spondylarthropathies, like Reiter's syndrome,
classic psoriasis, Bechterew's disease etc. We observed some cases of PAO that developed the
pattern of classic Bechterew's disease during the course of the disease.
In contrast to these classic seronegative spondylarthropathies, in PAO the sternocostoclavicular
region most often is involved, that may be considered as the anatomic counterpart of the sacroiliac
joints. As in classic spondylarthropathies, the pathogenesis of PAO may involve a faulty or
atypical immune response to viral or bacterial antigens. The latter are also present in the
pustules of the palmes and soles.
The radiologic features of SCCH consist of destructive changes in the manubrium and medial
clavicular segments combined with reactive-reparative zones of sclerosis. These may involve the
upper anterior ribs. Meanwhile, ossification of the intrerosseous ligaments creates a platelike effect
at the affected areas. These bony changes and concomitant soft tissue formations behind the SCCregion are best demonstrated at CT. In a scintigraphic bone scan SCCH is "hot", in typical cases we
see the "bullhead sign" (Freyschmidt and Sternberg, 1998).
In a large number of cases patients with PAO develop aseptic spondylitic changes that may be
accompanied by syndesmophytes or mixed osteophytes like in other seronegative
spondylarthropathies. Anterior to the spondylitic changes one can observe soft tissue formations
(Ormond-like fibrosis).
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In 14 cases (13%) of a total of 109 cases with PAO (1998-2002) patients developed extraaxial
manifestations of the disease, consisting of mixed destructive and proliferative changes that will be
discussed in detail. 6 patient are male, 8 are female. The age ranged from 20- 70 (mean 44).
All patients presented with pustulosis palmoplantaris (PPP) or had a history of PPP, or developed it
in the follow-up.
The pathologic and radiologic spectrum extended from calcifying tendinitis and enthesitis to
ossifying periostitis and osteitis, in some cases mimicking malignancy (i.e. juxtacortical or central
osteosarcoma). The following locations were found: 3 x scapula, 4 x femur, 1x fibula, 4 x tibia and
fibula, 1 x pelvis, 1 x epicondylus humeri, 1 x tarsus. 10 cases had additional sternocostoclavicular
hyperostosis (SCCH), 3 additional SCCH and spondylitis, 3 an additional spondylitis alone and
only one case showed an isolated bilateral ossifying periostitis at the tibia and fibula. One of the
cases with additional spondylitis showed a bilateral CRMO in the thights mimicking osteosarcoma.
Extraaxial manifestations of PAO are relatively rare, for the most part consisting of calcifying
periostits and osteitis that may mimic malignancy. They favour the scapula, femur, tibia, and fibula.
In most cases (10/14) they are associated with SCCH. Patients could be preserved from "diagnostic
odysees" and unnecessary "bloody" diagnostic procedures if the radiologist takes a look at the
patient's hands and feet (PPP) and if he considers typical manifestations of PAO like SCCH and
spondylitis, using a scintigraphic bone scan.
Abstract no. 99
THE SESAMOID INDEX IN PSORIATIC ARTHROPATHY
R.W. Whitehouse, R. Aslam, M. Bukhari
Dept. of Clinical Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
Aims: The sesamoid index was originally described as an aid to the diagnosis of acromegaly. We
performed this study to assess the value of the thumb sesamoid index in the diagnosis of psoriatic
arthropathy.
Patients and Methods: The sesamoid index (length x width of the medial thumb sesamoid), age
and sex were recorded for 56 consecutive patients attending a Rheumatology Clinic with arthralgia
and psoriasis. Comparison groups with radiographic evidence of rheumatoid arthritis, osteoarthritis
or normal hands were also recorded. Patients with psoriasis were subdivided into those with or
without radiographic evidence of hand arthropathy.
Results: 17 of 40 patients with psoriatic hand arthropathy had a sesamoid index >40, compared
with 1 of 40 with RA, none of 29 with OA and none of 55 normals.
Conclusions: Psoriatic arthropathy is a recognised cause of bone enlargement, usually in the
phalanges due to periostitis and proliferative enthesopathy. We have confirmed that psoriatic hand
arthropathy commonly causes significant enlargement of the thumb sesamoids, a feature which can
be easily quantified and may have diagnostic value.
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Abstract no. 100
MRI AS A DIAGNOSTIC TOOL TO EVALUATE ABACTERIAL SACROILIITIS IN
PATIENTS WITH LOWER BACK PAIN
Ph. Remplik, O. Schuckai, K. Bohndorf
Dept. of Radiology, Klinikum Augsburg, Augsburg, Germany
Purpose: To define sensitivity, specitivity, accurracy, NPV and PPV of MRI for the evaluation of
abacterial sacroiliitis in patients with lower back pain.
Material and Methods: 65 patients with the clinical suspicion of sacroiliitis referred by
rheumatologists for MRI of the SI joints were retrospectively reviewed. The MRI protocol included
T1-, STIR and T1-weighted sequences with fat saturation after i.v. administration of Gadolinium.
All patients were followed at least four years and the gold standard was defined by one
rheumatologist using all clinical, laboratory, imaging and follow-up data. The primary MRI report
was compared with defined gold standard.
Results: There was one false-positive, one false-negative MRI result. The sensitivity and specifity
was 94,7 % and 97,8 % respectively. An accurracy of 96,9 %, a PPV of 94,7 % and a NPV of 97,8
% was achieved.
Conclusion: In clinical routine MRI has proven to be an excellent tool to diagnose or exclude
sacroiliitis in patients with lower back pain.
Abstract no. 101
DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR JOINT (TMJ) INVOLVEMENT IN
PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS (JIA)
J. Gelineck3 , T. K. Pedersen1, A. Küseler1, T Herlin2,
1
Dept. of Orthodontics, 2Pediatric Rheumatology Clinic, 3Dept. of Radiology, University of Aarhus,
Denmark.
Introduction: TMJ arthritis is a frequent finding in children with JIA. It is characterized by few or
moderate symptoms and clinical findings although the consequences for the development of the
lower face can be dramatic. Early functional treatment seems to have an effect in controlling the
growth disturbances if intervention is instituted before deformities are present.
Aim: Prospectively to describe the development in the TMJ in a 2-year period in a group of
consecutively chosen patients with a diagnose of JIA with a disease duration no longer than three
years at baseline.
Patients and Methods: Fifteen consecutive selected patients with JIA were chosen for this
longitudinal study. Four magnetic resonance scans (MRI) and orthopantomograms (OTP)
examinations together with clinical examinations were done with 6 month intervals.The MR images
were obtained with iv injection of a contrast medium to reveal inflammation and described
according to soft tissue and bone changes. The OTP’s were described according to degree of
resorptions of the condyle. Functional treatment was started if inflammation were suspected.
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Results: Thirty percent of the patients had condylar resorption according to the OTP and there were
no changes seen in the two-year period. At MRI 58.6% showed erosions at the first examination,
statistical significantly (p<0.05, chi2-test) increasing to 80 % in the last examination. Clinical
examination indicated inflammation by decrease of opening capacity (<40 mm) and lack of
palpable translation of the condylar head.
Conclusion: The diagnostic value of OTP, which is an often used screening method, is too low and
cannot be recommended to find early TMJ involvement. Monitoring changes in TMJ function seem
to be more reliable and functional inability should be the indication for functional treatment rather
than radiographic changes. MRI may be of diagnostic help.
Abstract no. 102
PAINFUL CERVICAL CALCINOSIS IN A SCLERODERMA PATIENT (CASE REPORT)
S.Van de Perre 1,2, F.M.Vanhoenacker1,2, J.Gielen1, A.M. De Schepper1.
Dept. of Radiology1, University Hospital Antwerp, Wilrijkstraat, 10, B-2650 Edegem, Belgium
Dept. of Radiology2, AZ Sint Maarten, c. Duffel, Rooienberg, 25, B-2570 Duffel, Belgium
Purpose: The purpose of this presentation is threefold: 1) To report the imaging features of a rare
case of scleroderma associated cervical calcinosis. 2) To report the strength of each imaging
technique. 3) To discuss the differential diagnosis with other cervical calcifications.
Methods and Materials: 74-year-old woman with known longstanding scleroderma presented with
chronic neck pain. On conventional radiography and CT, there were lobular calcifications at the
posterolateral aspect of the upper cervical spine, which were centered on the facet joints.
On MRI, these masses were hypointense on both pulse sequences. There was no enhancement.
Minor intraspinal extension was seen.
Results and discussion: Although soft tissue calcifications are well known to occur as a late
manifestation in scleroderma, symptomatic paraspinal calcinosis is very rare. Clinically, patients
present with focal neck pain, weakness or radiculopathy and decreased range of motion of the neck.
Standard radiography is usually sufficient to confirm the diagnosis, but CT-scan allows a more
precise location of the calcifications around the facet joints, sometimes with associated erosions.
The advantage of MRI is to evaluate the possible intraspinal extension of these calcifications, in
case of focal neurological symptomatology.
The differential diagnosis includes mainly CPPD and HADD of the cervical spine.
Abstract no. 103
ADHESIVE CAPSULITIS OF THE SHOULDER: SONOGRAPHIC APPEARANCES
C. Sykes, D. Connell, F. Malara
Dept. of Medicial Imaging, St. F.X Cabrini Hospital, 183, Wattletree Rd, Malvern, Victoria 3144, Australia
Purpose: Adhesive capsulitis is a clinical syndrome characterised by pain and severe limitation of
joint movement. Arthroscopic and MR appearances of adhesive capsulitis are characterised by
vascular proliferation of synovial tissue within the rotator interval and axillary pouch, however the
sonographic appearance of the disease has not been described. The purpose of this study was to
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identify and describe sonographic changes involving the rotator interval in patients with a clinical
diagnosis of adhesive capsulitis.
Materials and Methods: Thirty patients (20 females, 10 males, mean age 52 yrs.) with clinically
diagnosed adhesive capsulitis were assessed sonographically. Of these, 26 patients described
symptoms existing less than one year, with 4 patients exhibiting long standing (> 1 year) symptoms.
Over the same period, 100 patients presented for rotator cuff evaluation with no clinical suspicion
of adhesive capsulitis. In both groups of patients, the rotator interval was scrutinised using greyscale and colour Doppler sonography. Particular attention was given to the echogenicity and
vascularity of the rotator interval. The rotator interval was also assessed in 10 asymptomatic
volunteers.
Results: The contents of the rotator interval including the coracohumeral and superior
glenohumeral ligaments are clearly discerned with ultrasound. Abnormalities of the rotator interval
were identified in 29/30 patients with clinical evidence of adhesive capsulitis. Increased vascularity
superimposed on a background of hypoechoic change within the rotator interval, particularly
involving the subscapular recess, was seen in 26/30 patients. Hypoechoic change with no
hyperaemic change was seen in 3/30 patients. Similar changes in the rotator interval were not
identified in patients with rotator cuff pathology, nor were they seen in normal subjects. No
sonographic abnormality could be detected in 1/30 patient with clinical symptoms.
Conclusion: Enhanced vascularity and hypoechoic change within the rotator interval are useful
criteria for the sonographic diagnosis of adhesive capsulitis. These findings correlate with the
arthroscopic and MR description of adhesive capsulitis.
Abstract no. 104
POLYMYALGIA RHEUMATICA: COMPLEX IMAGING
P.N. Kaposi, A.R. Mester, K. Karlinger, Z. Schmidt
MRI Centre of National Institute of Rheumatology and Physiotherapy
Department of Diagnostic Radiology and Oncotherapy, Semmelweis University, Budapest, Hungary
Introduction: Polymyalgia rheumatica (PMR) of distal musculoskeletal manifestation could create
diagnostic difficulties. Bilateral subacromial / subdeltoid bursitis has a diagnostic impact.
Purpose: In a recent MRI casecontrol studies we found subacromial/subdeltoid bursitis in 100 % of
PMR cases, while this lesion was observed in only 22 % of controls with rheumatoid arthritis (RA).
We evaluated whether shoulder ultrasonography (US) was as effective as MRI in the detection of
bilateral subacromial/subdeltoid bursitis.
Patients and Methods: The authors adopted the following methods in the case of their own 17
patients: ultrasonograpy, color duplex Doppler and magnetic resonance imaging. It was a casecontrol study of 17 consecutive patients with untreated PMR. In all case the glenohumeral joint
space, bursae, and long head biceps tendon were assessed by shoulder US and MRI.
Results and Conclusion: US and MRI were equally effective in confirming bilateral
subacromial/subdeltoid bursitis in PMR. MRI is considered the gold standard imaging method for
both articular and extraarticular inflammatory lesion of the shoulders. Ultrasonograpy (US) may
represent a valid, less expensive alternative method for detection of shoulder soft tissue
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inflammatory changes. US and colour duplex Doppler US is a quick, easy and non invasive method
to obtain information about inflammation of the temporal arthritis.
Abstract no. 105
DEDICATED EXTREMITY 0.2 T MRI OF THE FINGER JOINTS: DISTRIBUTION OF
SYNOVITIS IN PATIENTS WITH ARTHRITIS.
A. Savnik, H. Malmskov, I.L.B. Graff, H. Nielsen, B. Danneskiold-Samsøe, J. Boesen, H. Bliddal,
H.S. Thomsen
Dept. of Radiology and Rheumatology, Universiy Hospital of Herlev and Frederiksberg Hospital and Parker
Inst., Copenhagen, Denmark
Aim: To compare the volumes of synovitis (Vsyn) in the metacarpophalangeal (MCPJ), proximal
and distal interphalangeal joints (PIPJ and DIPJ) in patients with arthritis and the predilection of
synovitis.
Methods: 28 rheumatoid arthritis (RA) patients < 3 years, 25 other arthritis patients and 25 RA
patients > 3 years underwent 0.2 T MRI.
Results: The 2nd and 3rd MCPJs had the greatest Vsyn in RA. The greatest Vsyn was found in RA
> 3 years. These joints also had the highest frequency of synovitis. A predilection for synovitis was
46 % in the 2nd and 43 % in the 3rd MCPJ in RA < 3 years and 52 % in the 2nd and 40 % in the
3rd MCPJ in RA > 3 years.
In patients with other arthritis the greatest median Vsyn was found in 2nd PIPJ and in the 2nd
MCPJ. The Vsyn was not significantly different from the volumes found in RA patients. A
predilection for synovitis was 36 % in the 2nd MCPJ and 28 % in the 5th MCPJ and 4th PIPJ.
Conclusion: A predilection for synovitis was found in the 2nd and 3rd MCPJs in RA patients. 2nd
MCP joint was also mostly affected in patients with other arthritis.
114
th
Saturday, 14th June, 01.00 – 02.50 p.m. – Arthritis – Session 7a
Chair: J. Beltran (USA), M. Oestergaard (DK)
Abstract no. 106
DEVELOPMENT OF A SYSTEM FOR COMPUTER AIDED DIAGNOSIS (CAD) IN
RHEUMATOID ARTHRITIS (1): AUTOMATED JOINT LOCALIZATION IN HAND
RADIOGRAPHS.
L. Peloschek1, G. Langs1, H. Bischof 2, F. Kainberger1,W. Kropatsch1, H. Imhof 1
1
Dept. of Diagnostic Radiology, University of Vienna, 2Graz, Austria
Aim: The aim of this project is the development of methods to perform an automated analysis of
serial hand radiographs. An exact identification of joint locations in hand radiographs of patients
with rheumatoid arthritis is proposed as a first step for further investigation of these joints.
Material and Method: The computational localization is performed on a commercially available
laptop on digital radiographs, the algorithm was optimized during an offline training phase.
Reliability as well as processing time for the overall procedure was determined by repeating the
measurements. No manual initialization is required for the localization procedure. Statistical
analysis was done on the CMC-, MCP- and DIP-joints of 20 subjects.
Results: Accuracy and precision of measurements were found to be sufficiently robust (median
position error 2.78mm) by means of further processing with active shape models. The processing
time for a radiograph on a Celeron 566MHz CPU is ~6 sec.
Conclusion: A feasible and robust way to initialize automated quantification of bone lesions of
sufficient is proposed. These methods are not only applicable for hand radiographs but also for
image recognition in other radiological tasks.
Abstract no. 107
RHEUMATOID ARTHRITIS (2): AUTOMATED ESTIMATION OF THE BONY CONTOUR
OF METACARPAL BONES.
G. Langs1, P.L. Peloschek1, H. Bischof 2, F. Kainberger1,W. Kropatsch1, H. Imhof 1
1
Aim: The aim of this project is the development of methods to perform an automated analysis of
serial hand radiographs. After an exact automated identification of joint locations in hand
radiographs of patients with rheumatoid arthritis the estimation of the bony contour is the next step
to further image analysis.
Material and Method: The algorithm is performed on a commercially available laptop on digital
radiographs. The training of the algorithm was performed on two training sets T15 and T30
consisting of n=15 and n=30 sample radiographs. Evaluation was done on 10 different radiographs.
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Results:
The algorithm locates the bone contour with high accuracy. Median error orthogonal to the contour
was 0.113mm with T30. With T30 74.6% of the landmarks in the test set lie within a 0.25mm error
corridor around the true bone contour. Only overlapping bones slightly deteriorate the result.
Conclusion: A method for automated estimation of the bony contour is proposed. The result of this
algorithm is a parametrical description of the identified shape. This algorithm is generalizeable and
will be applied to other anatomical regions.
Abstract no. 108
RHEUMATOID ARTHRITIS (3): AUTOMATED DELINEATION OF DEFECTS OF THE
BONY CONTOUR OF METACARPAL BONES.
P.L. Peloschek1, G. Langs1, H. Bischof 2, F. Kainberger1,W. Kropatsch1, H. Imhof 1
1
Aim: Recent developments allow automated detection of bone contours resulting in a parametrical
description of the identified shape. Automated discrimination of pathological changes of shape is
the next step towards computer aided diagnosis (CAD) and quantification of erosions in
rheumatoid.
Material and Method: Knowing the shape of a not affected bone, erosions show characteristics
that can be described by means of contour features like concavity and roughness. Among other
automatically derived indicators the degree of concavity of a contour deformation therefore gives
information about the probability of this contour deviation to be an erosion. Experiments were
performed on a commercially available laptop on digital radiographs.
Results: Experimental investigations on MCP joints show promising results that will be presented.
The features extracted from the algorithm show good discriminative properties. Exemplary cases
will be shown.
Conclusion: A method for automated detection of bone erosions in rheumatoid arthritis is
proposed. This algorithm is generalizeable and can be applied to other anatomical regions. An
algorithm to automatically classify features extracted from the contour identification with respect to
detect and classify erosions automatically is work in progress.
Abstract no. 109
COURSE OF RADIOGRAPHIC DAMAGE OVER 10 YEARS IN A COHORT WITH EARLY
RHEUMATOID ARTHRITIS
E. Lindqvist, K. Jonsson, T. Saxne, K. Eberhardt
Depts. of Rheumatology and Radiology, Lund University Hospital, Lund, Sweden
Purpose: To investigate development of radiographic damage in hands and feet of patients with
early rheumatoid arthritis (RA) monitored prospectively for 10 years and to search for prognostic
factors.
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Patients and Methods: 181 patients with early RA were assessed annually with radiographs of
hands and feet during years 0-5 and at year 10. Radiographs were evaluated according to Larsen
(range 0-200). Predictive factors for progressive disease years 0-5 and 5-10 were evaluated by
logistic regression analyses.
Results: 82/168 (49%) patients had erosions at inclusion and almost all became erosive with time
(90% after 2 years and 96% after 10 years). Radiographic progression was most rapid during the
first two years and 75% of all damage occurred during the first five years. The median Larsen score
increased from 6 at inclusion to 41 after 5 years and 54 after 10 years. ESR from the first 3 months
and rheumatoid factor status were significant predictors for radiographic progressive disease.
Conclusions: Joint damage in hands and feet developed early and progression was most rapid
during the first years of disease. The different rates of progression at different stages should be
considered in the design of trials of drugs aimed at retarding joint damage.
Abstract no. 110
MRI OF THE NON-DOMINANT WRIST AND MCP-JOINTS PREDICTS RADIOGRAPHIC
PROGRESSION IN BOTH WRISTS, METACARPOPHALANGEAL AND PROXIMAL
INTERPHALANGEAL JOINTS (TOTAL SHARP SCORE) IN ANAKINRA-TREATED
RHEUMATOID ARTHRITIS PATIENTS.
M. Østergaard, H. Nielsen, E. Narvestad, J.S. Johansen, B. Baslund, B.J. Ejbjerg, H.S. Thomsen, J.
Petersen.
Depts. and Labs. of Rheumatology and Radiology, Copenhagen University Hospital at Herlev, Hvidovre and
Rigshospitalet, Denmark
Aim: To evaluate MRI, in comparison with conventional clinical, biochemical and radiographical
methods, for describing and predicting the course of joint inflammation and destruction in
rheumatoid arthritis (RA) patients treated with Anakinra (recombinant human interleukin-1 receptor
antagonist; a newly-approved biological RA-therapy).
Methods: 17 clinically active RA patients (duration: 2-37y, median 13y) received Anakinra 100 mg
s.c./daily for 36 weeks. MRI (T1-w, pre-&post-Gd, coronal&axial) of the non-dominant wrist and
2nd-5th MCP-joints (week 0+12+36), bilateral radiographs of wrist+MCP+PIP-joints (week 0+36)
and standard clinical/biochemical parameters (week 0+2+4+12+24+36) were available.
Results: While Anakinra significantly reduced clinical and biochemical markers of disease activity
(Wilcoxon-Pratt;p<0.001-p<0.05), MRI-synovitis scores remained unchanged. Accordingly, the
majority of patients experienced progressive joint destruction (MRI: 12 patients; radiographs: 11
patients).
The baseline MRI-synovitis score was highly correlated with the week 0-36 increase in total
number of radiographically eroded bones (wrists+MCP+PIP)(rho=0.70;p<0.01) and with the total
Sharp score at month 36 (rho=0.61;p<0.05). The week 0-12 increase in MRI-erosion score
correlated with the week 0-36 total Sharp score increase (rho=0.55;p<0.05). MRI-scores and
radiographic progression were not significantly correlated with clinical or biochemical disease
activity markers.
Conclusion: MRI of the non-dominant wrist and 2nd-5th MCP-joints showed erosive progression
in more patients than radiographs of both hands and wrists, and baseline scores and early changes in
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MRI-parameters in these few joints were highly correlated with the subsequent progression in Sharp
scores from both hands and wrists.
MRI is superior to radiography for monitoring and prediction of rheumatoid joint damage and for
quick evaluation of treatment efficacy in RA.
Abstract no. 111
MRI OF THE WRIST AND FINGER JOINTS IN PATIENTS WITH ARTHRITIS.
CORRELATION BETWEEN DEDICATED EXTREMITY MRI (E-MRI) AND CLINICAL
FINDINGS.
A. Savnik,
Parker Institute, Charlottenlund, Denmark
Aim: To correlate both quantitative and qualitative MRI findings with clinical markers of disease
activity.
Patients and Methods : E-MRI of the wrist and finger joints was performed in 28 patients with
rheumatoid arthritis (RA) <3 years, 25 patients with other arthritis and 25 patients with RA >3 years
with coronal STIR and 3D T1-WI after Gd.
Results: In RA (< 3 years) swollen joint count in the wrist correlated with presence of bone edema
in the navicular, lunate and triquete bone (Spearman rho (Rs) = 0.47-0.49 P< 0.01). In patients with
other arthritis the synovial volume in the finger joints correlated with score of disease activity (Rs =
0.56, P=0.005). Swollen joint count in the wrist correlated with bone edema in the carpal bones (Rs
= 0.42-0.47, p= 0.04). In RA > 3 years swollen joint count correlated with bone edema of the radial,
ulnar and carpal bones (Rs = 0.42, p=0.04), and tender joint count correlated with synovial
enhancement (Rs = 0.63, p= 0.001-0.03).
Conclusions: Bone edema on MRI seem to be correlated with the clinical disease activity
measurement swollen joint count in the wrist. Synovial volume was not correlated to either swollen
or tender joint count.
Abstract no. 112
MEASUREMNT OF ENHANCING PANNUS VOLUME IN THE HAND IN RHEUMATOID
ARTHRITIS (RA) USING IMPROVED POST- MINUS PRE-CONTRAST-ENHANCED T1WEIGHTED MRI
E. Xanthopoulos1, C.J. Taylor1, C.E. Hutchinson1, J.E. Adams1, I.N. Bruce2, A.F. Nash3, J.C.
Waterton3.
1
Imaging Science and Biomedical Engineering, Stopford Medical School, Oxford Road,
Manchester, M13 9PT.
2
Department of Rheumatology, Manchester Royal Infirmary;
3
AstraZeneca, Alderley Park Macclesfield, Cheshire, UK.
Aims: Determination of pannus volume (PV) on MRI is related to disease activity and of value in
predicting treatment outcome in RA. Few studies have investigated longitudinal changes of pannus
volume, and none over very short periods of time (< 6 months). The study examines the precision of
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the measurement method (scans at 0 and 1 week), the change at two other time points (1 and 13
weeks) and aims to produce improved accuracy of PV measurements
Patients and Methods: 13 patients (1 male), age: mean 54; range 33-70 years with RA (duration:
mean 6; range 1.5-10 years). The dominant hand was scanned. 3D MR images were acquired using
a dedicated surface receiver-only hand and wrist coil and consisted of coronal, fat-suppressed
gradient echo T1-weighted (W) sequence, followed by T1W Gd-DTPA contrast-enhanced images.
To accurately delineate enhancing pannus, apart from other enhancing structures, 3D models and
Maximum Intensity Projections of the ‘shuffle subtraction’ images (T1 post Gd –T1 Pre Gd) were
used. PV (cm3) was measured at the radio-ulnar, radio-carpal, mid-carpal and MTP joints
Results: Reproducibility was 0.14 (CoV), and significant changes in PV were detected after 3
months. Measurements from a single 2D mid-coronal slice were correlated to total volume,
suggesting that restricting PV measurements to a single section may be a quick, and more clinically
practical, alternative to the more time consuming volumetric image acquisition.
Conclusions: This MR method of imaging and measuring enhancing pannus volume may provide a
sensitive monitor of RA disease progression and response to therapy
Abstract no. 113
ANALYSIS OF SYNOVIAL MICROVASCULARIZATION IN PATIENTS WITH RHEUMATIC
DISEASES USING CONTRAST ULTRASOUND:PRELIMINARY RESULTS
A.De Marchi, L.Verga, P. De Petro, E.Cenna, C. Faletti
Dept. of Radiology, Inst. De Radiologia CTO-CRF-M. Adelaide, Torino, Italy
Purpose: To clarify if Contrast Ultrasound(CU) is able to distinguish between liquid or solid
lesions and, above all, demonstrate the microvascularization of synovial proliferation in patients
with rheumatic diseases.
Materials and Methods: 34 patients with various degrees of synovial pathology were examined.
All patients underwent gray-scale US evaluation. After routine examination, CU was performed;
low mechanical index were used. A new contrast agent (SonoVue, Bracco) was administrated as
bolus intravenous injection. All patients were also examined with contrast enhanced MRI using a
low field unit dedicated for the evaluation of extremities as gold standard.
Results: In all cases CU gave optimal information about liquid or solid images like pannus pattern
and showed a clear enhancement inside the synovial proliferation that improved the visualization
and discrimination of hyperplastic synovial nodules.
Conclusions: Our preliminary results suggest that CU is able to evaluate the microvascularization
of synovial proliferation demonstrating an important diagnostic role to assessing synovial activity
especially in the follow up of patients with rheumatic diseases during and after therapy, similar to
second level examinations such as contrast-enhanced MRI. It’s also very useful the possibility of
correlation, now and in the future, with our images and histological results.
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Abstract no. 114
CORRELATION OF POWER DOPPLER SONOGRAPHY WITH VASCULARITY OF THE
SYNOVIAL TISSUE
G. Labanauskaite
Dept. of Radiology, Kaunas Medcial Univesity Kaunas, Lithuania
Purpose: The purpose of this study was to investigate the intra-articular vascularisation of the
synovium with power Doppler sonography (PDS) and correlate these findings with histopathologic
findings of synovial vascularity.
Material and Methods: Before arthroplasty or arthroscopy with synovectomy the knee joints of 20
patients with osteoarthritis or rheumatoid arthritis were examined with PDS. The PDS vascularity
of the synovial membrane was classified semi quantitatively. Histological the degree of the
synovial vascularity was graded quantitatively.
Results: A strong correlation was found between qualitative PDS results with histological findings
of vascularity (Spearman’s correlation coefficient was 0,85, p=0,0005).
Conclusion: PDS may be a valuable tool to detect synovial vascularity and to assist clinicians in
distinguishing between inflammatory and non-inflammatory synovium.
Abstract no. 115
EROSIVE EARLY RHEUMATOID ARTHRITIS (RA) IN FINGER AND TOE JOINTS ON
ULTRASONOGRAPHY (US), MAGNETIC RESONANCE IMAGING (MRI) AND
CONVENTIONAL RADIOGRAPHY (CR)
M. Szkudlarek1, M. Klarlund2, E. Narvestad3, M. Court-Payen4, M. Østergaard1,5.
1
Dept. of Rheumatology, 2The Danish Research Center of Magnetic Resonance and
Dept. of Radiology, Hvidovre Hospital; 4Dept. of Ultrasound and 5Rheumatology,
Herlev Hospital; University of Copenhagen, Denmark
3
Aim: To investigate the pattern of erosive disease in early RA on US, MRI and CR.
Methods: US, MRI, and CR were performed on the 2nd–5th MCP and PIP joints of the dominant
hands and, within the four following weeks, on the 1st–5th MTP joints of the right feet of 17
patients with early RA and 6 healthy control persons.
Results: Seven patients had no signs of erosive disease on any of the modalities. Ten patients had
erosive disease on US, 6 on MRI and 2 on CR. In 3 patients erosions were found in both the finger
and toe joints on US, in 2 on MRI. 64% of bone erosions on all modalities were found in the finger
joints. No erosions were visualized in the control persons.
Conclusions: US detected erosive disease more often than MRI and CR in the early RA patients.
The majority of the detected bone erosions were found in the finger joints, while rarely in both
finger and toe joints.
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Abstract no. 116
EPIDURAL PANNUS AS AN UNDERESTIMATED CAUSE OF SUB-AXIAL CERVICAL
SPINE STENOSIS IN RHEUMATOID ARTHRITIS
L.J.M. Kroft, M. Reijnierse, M. Kloppenburg, B.M.Verbist, J.L. Bloem, M.A.van Buchem
Dept. of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The
Netherlands.
Purpose: To assess the prevalence and site of sub-axial spinal canal stenosis based on enhancing
tissue in patients with rheumatoid arthritis (RA), and to compare this with patients with
degenerative cervical spine disease.
Patients and methods: 33 consecutive patients with RA were evaluated with 1.5 T MR imaging
following gadolinium-chelate administration in combination with a frequency selective fat
suppression technique. Stenosis and enhancement were scored for each of six cervical spine levels
and compared to 16 patients with degenerative disease.
Results: No significant difference was found in the frequency or severity of sub-axial stenosis
between RA and degenerative disease. Epidural enhancement was observed more often in RA than
in degenerative disease anterior (73/198 vs 7/97, P = 0.000) and posterior to the spinal cord (60/198
vs 5/96, P = 0.000). Enhancing stenosing tissue in RA frequently occurs anterior and posterior at the
same time at the same level, with segmental cuff-like extension of enhancing tissue around the dural
sac. Stenosing tissue enhanced more frequently in RA than in degenerative disease (54/128 vs. 6/53,
P = 0.000).
Conclusion: Only in RA patients, subaxial stenosis is frequently based on enhancing epidural
tissue, probably representing pannus. This observation may have therapeutic implications.
121
th
Saturday, 14th June, 08.30 – 10.00 a.m. – Bone tumours and hyemophilia – Session 5b
Chair: A.M. Davies (UK), B. Lundin (SE)
Abstract no. 117
DEDIFFERENTIATED CHONDROSARCOMA OF THE APPENDICULAR SKELETON: MRIPATHOLOGICAL CORRELATION.
P. O’Donnell1, A. Saifuddin1, F. Mac Sweeney2, A. Darby2.
Depts. of Radiology1 and Histopathology2, RNOHT, Stanmore, Middlesex HA7 4LP. UK
E-mail: PO\’[email protected]
Purpose: To correlate the T2W/STIR MRI appearances of dedifferentiated appendicular
chondrosarcoma with gross and microscopic pathology.
Material and Methods: Ten patients with a histologically confirmed diagnosis of dedifferentiated
appendicular chondrosarcoma were identified from the Bone Tumour Registry. All patients
underwent MRI, including T2W or STIR sequences in at least one plane, prior to limb salvage
surgery. Areas of intermediate or reduced signal intensity (SI) on the T2W/STIR images were
correlated with the resection specimen to determine the relationship of such reduced SI areas with
regions of dedifferentiation.
Results and Conclusions: Patients presented over a period of 7 years. There were 5 males and 5
females with mean age of 68.2 years and age range 51-78 years. Tumours arose in the femur (7
cases), humerus (2 cases) and tibia (1 case). Areas of lobulated, high SI on T2W MRI corresponded
to regions of grade 1 or grade 2 chondrosarcoma. However, areas of reduced SI on T2W/STIR MRI
correlated closely to regions of dedifferentiation, either osteosarcoma or MFH. In patients with
suspected chondrosarcoma, T2W/STIR MR sequences should be carefully assessed for areas of
reduced SI, which may indicate dedifferentiation and such areas should be the preferred site of
biopsy.
Abstract no. 118
REPRESENTATIVENESS OF RADIOLOGICALLY GUIDED FINE-NEEDLE ASPIRATION
BIOPSY OF BONE LESIONS
V. Söderlund, E. Tani, H.A. Domanski, A. Kreicbergs
Dept. of Diagnostic Radiology, ADR, Karolinska Hospital, S-171 76 Stockholm, Sweden
Purpose: To analyze the representativeness of radiologically guided fine needle aspiration biopsy
of bone lesions.
Material and Methods: The consistency of the cellular yield of FNAB was investigated in 29
cases with bone lesions. Aspirates from three different sites of the same lesion were analyzed
randomly and independently in blinded manner by two cytologists. Four categories were used: 1)
benign, 2) sarcoma, 3) other malignancy, 4) non-conclusive.
A lesion was considered homogenous, when all 3 aspirates were identically categorized.
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Results: Among 29 lesions, 13 and 12, respectively, were assessed as homogenous by the two
cytologists. In the remaining lesions, heterogeneity almost exclusively pertained to the mixture of
conclusive and non-conclusive aspirates. Two alternative diagnoses were suggested in 1 case by
each cytologist.
The two cytologists' assessments showed compliance in 21 cases (63 aspirates) and non-compliance
in 8 (24 aspirates). The differences between the cytologists were the ratio of aspirates assessed as
conclusive v. non-conclusive. Only the analysis of one and the same aspirate resulted in two
different diagnoses. A correct diagnose was given by the cytologists in 22 and 23 cases, incorrect in
2 and non-conclusive in 5 and 4, respectively.
Conclusion: Our study, albeit limited, suggests that true tumour heterogeneity is rare. The noncompliance between the two cytologists and the diagnostic difficulties should mainly be attributed
to the blinded, random approach of the study.
Abstract no. 119
COMBINED RADIOLOGY AND CYTOLOGY IN THE DIAGNOSIS OF BONE LESIONS A
RETROSPECTIVE STUDY OF 370 CASES
V. Söderlund, L. Skoog, A. Kreicbergs
Dept. of Diagnostic Radiology, ADR, Karolinska Hospital, S-171 76 Stockholm, Sweden
Purpose: To evaluate the validity of combined radiology and fine needle aspiration cytology in the
diagnosis of bone lesions.
Material and Methods: A consecutive series of 370 cases were analyzed retrospectively. In 234
cases the treatment diagnosis was based on radiology and cytology solely, whereas in 136 cases also
histopathology was applied.
Results: Comparison of radiology and cytology showed diagnostic compliance in 256 cases (69 %)
and non-compliance in 101 (28 %). 13 (3 %) cases failed to yield diagnostic material for cytology.
Among the 256 compliant cases, the diagnostic error rate was 0.8 % (2 falsely benign), whereas
among the 101 non-compliant cases the rate was 16.8 % (17 cases). In the latter group, 36 cases
yielded only normal cells at aspiration, out of which 20 proved to have a neoplastic lesion (8
metastases, 12 benign). Sensitivity was 90.2 %, specificity 95.3 %, predictive positive and negative
predictive value was 97.4 % and 83.7 % respectively.
Conclusion: Our study suggests that a simple approach based on conventional radiography and fine
needle aspiration cytology offers a valid means of diagnosing bone lesions. Provided there is
compliance between radiology and cytology, the risk of false diagnosis is below 1 %.
Abstract no. 120
WHOLE-BODY MRI IN PRIMARY MALIGNANT BONE TUMORS USING A MOVING
TABLE TOP AND COMPARISON WITH BONE SCINTIGRAPHY
1
C.R.Krestan, 2C.Toma, 2M.Dominkus, 3A.Kurtaran, 1S. Marihart, 2P. Zwolak, 1H. Imhof, 1M.
Breitenseher, 1F. Kainberger
1
2
Department of Radiology, University of Vienna, 1090 Vienna, Austria
Department of Orthopedic Surgery, University of Vienna, 1090 Vienna, Austria
123
3
Department of Nuclear Medicine, University of Vienna, 1090 Vienna, Austria
Purpose: To evaluate the diagnostic value of whole-body MRI in the diagnostic workup of patients
with primary malignant bone tumors.
Materials and Methods: Twenty patients (mean age: 31 years, range: 12-76 years) underwent
whole-body MRI on a 1.0 MRI scanner (T10-NT, Philips Medical Systems, Best Netherlands) with
a moving table-top. Coronal T1-SE and coronal STIR sequences were performed covering almost
the entire skeleton. Whole body MRI scans were read by two experienced musculoskeletal
radiologists and compared to bone scintigraphy (Tc99m DPD) in 12 (60%) of patients and in one
patient to F-18 FDG PET.
Results: There was agreement in 10 out of 12 patients (83%) with whole-body MRI and bone scan
available. Of the 2 patients without agreement, bone scan was false positive in one case and missed
4 out of 5 lesions in a patient with a multifocal Ewing sarcoma. Whole-body MRI could detect all
lesions in this patient. In one patient whole-body MRI missed a lesion in the forefoot, which was
detected by F-18 FDG PET.
In two of seven cases without comparative nuclear medicine studies whole-body MRI was able to
demonstrate skip lesions.
Conclusion: To our experience whole-body MRI seems to be more sensitive than bone scintigraphy
in multifocal primary bone tumors and is a promising tool in diagnosing skip lesions. Limitations of
the method are due to the fact that not the entire skeleton is covered. Further studies are necessary
to evaluate this new method.
Abstract no. 121
IMAGING OF BONE FORMING TUMORS
J.M. Park, J.Y. Kim, M.S. Sung, W.H. Jee, K.A. Chun
Dept. of Radiology, St. Mary’s Hospital, The Catholic University of Korea, Seoul, South Korea
Aim: To present the imaging findings of the various bone forming tumors and discuss the role of
imaging modalities currently used in evaluation of the bone forming tumors.
Material and Methods: Eleven benign and twenty six malignant bone tumors were included. We
performed plain radiography in all cases, CT in 7, MR in 32 and bone scintigraphy in 27.
We present imaging findings in 11 cases of benign bone tumors (1 osteoma, 2 enostoses, 7 osteoid
osteomas including intracortical, intracapsular, subperiosteal location, and 1 osteoblastoma) and 26
malignant bone tumors (20 conventional intramedullary osteosarcomas, including 2 telangiectatic
osteosarcoma, 3 surface osteosarcomas, 1 secondary osteosarcoma and 2 multifocal
osteosarcomatosis).
Results: Radiographs remain the mainstay in the histologic diagnosis of bone forming tumor by
evaluation of location, margin, matrix mineralization, cortical involvement and periosteal reaction
of the lesion. Bone scintigraphy is an excellent screening modality with detection of skip lesions.
CT is especially useful in evaluating the detail of lesions including matrix mineralization. The
superior soft tissue resolution and multiplanar capabilities achieved with MRI, however, had
replaced the need for CT in many cases.
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Abstract no. 122
VALUE OF CONVENTIONAL RADIOGRAPHY IN DETECTION OF PRIMARY BONE
TUMOURS
C. Müller1, H.Imhof2, F. Kainberger2,
1
Dept. of Radiology, General Hospital Mistelbach, Mistelbach, Austria
Dept. of Radiology, University of Vienna,Austria
2
Purpose: To evaluate the role of conventional radiographs in detection of primary malignant bone
tumours.
Methods: We retrospectively reviewed the images and medical records of 80 patients with
histological proven primary or potentially malignant bone tumours.
Results: Clinical symptoms ranged from a non-tender mass to a pathologic fracture. The most
common symptom was local pain (84%). In 69 out of 80 patients conventional radiography was the
first imaging modality and in 87% the malignant character of a bone lesion was correctly identified
radiographically. There was no significant difference concerning false diagnosis comparing the
results of radiologists working in hospitals to the results of radiologists in private practices. Bone
tumours that predominantly affect adults needed a longer time of diagnosis than bone tumours with
main manifestation in childhood. The median age of patients with delayed imaging was significant
higher compared to the median age of patients, where radiographs were obtained immediately.
Conclusion: Conventional radiography is the most common initial imaging method for bone pain
and continues to play an important role to reduce the time gap between first onset of symptoms and
definitive treatment. The presence of primary bone sarcomas should be taken into consideration not
only in children but also in patients above the adolescence presenting with unremitting pain.
Abstract no. 123
CORRELATION BETWEEN MAGNETIC RESONANCE (MRI) AND ULTRASOUND (US) IN
THE ASSESSMENT OF KNEE ARTHROPATHY IN HEMOPHILIC CHILDREN.
Z. Czyrny*,A. Klukowska**, M.Brzewski***, P.£aguna**, R.Rokicka-Milewska**.
*Currently - Carolina Medical Center ([email protected]), Warsaw Poland, During the presented
study - Department of Ultrasound, IInd Faculty of Warsaw Medical Academy, Poland;
**Department of Pediatrics Hematology and Oncology, Ist Faculty of Warsaw Medical Academy Children’s
Hospital, Poland; ***Diagnostic Imaging and Radiology Department of Ist Faculty of Warsaw Medical
Academy Children’s Hospital, Poland.
Materials and Methods: Fifteen knees in fourteen patients were assessed with US and MRI for the
presence of fluid (MRI, US), synovial proliferation (MRI,US), hyperperfusion (US/Power Doppler),
cartilage degeneration and presence of subchondral cysts (MRI, US).
Examinations were performed up to a week before and six months after isotope (Y90)
synovectomy. MRI assessment of the presence of fluid, synovial proliferation, cartilage
degeneration and subchondral cysts was based on Nuss progressive scale. US assessment of the
presence of fluid and synovial proliferation was based on a 0-3 point scale. Hyperperfusion of the
synovium was assessed due to 0-4 point scale. Cartilage degeneration was based on Outerbridge’s
scale and subchondral cysts were counted separately. To compare US and MRI own adding scale
125
was created. The presence of fluid and synovial proliferation was assessed in 0-3 point scale and
subchondral cysts and cartilage degeneration were assessed in 0-2 point scale.
Results and Conclusion: Correlation coefficient between MRI and US in the assessment of
cartilage degeneration and presence of subchondral cysts was 0,95; 0,39 in the assessment of fluid
and 0,65 in the assessment of synovium. Our present experience shows that US is comparable to
MRI diagnostic tool in the assessment of the hemophilic knee joint especially as far as the
synovium, cartilage and presence of subchondral cysts are concerned. US is superior to MRI in the
assessment of synovial hyperperfusion.
Abstract no. 124
A MR-SCORE FOR HEMOPHILIC ARTHROPATHY
B. Lundin1, R. Ljung2, H. Pettersson 1
1
Dept. of Radiology, University Hospital of Lund, 2Dept.of Coagulation Disorders and Dept. of Pediatrics,
University Hospital of Malmoe, Sweden.
Purpose: To design a MR-score for hemophilic arthropathy, and investigate intra- and interobserver
agreement of assessments made with this score.
Methods and Patients: A MR-score was designed in the format A(e:s:h). A is the sum of points in
three categories of irreversible changes: subchondral cysts (6 points), irregularity/destruction of
subchondral cortex (4 points) and chondral destruction (6 points). The factors e, s and h represent
effusion/hemartrosis, synovial hypertrophy and hemosiderin respectively, and are evaluated
separately using a 5 step scale (0-4). Maximal score is 16(4:4:4).
Thirdty-nine ankles in 28 boys aged 4-16 (mean 10) years with hemophilia were investigated with
MR, and classified with the MR-score twice by two radiologists. The results were compared by
calculation of kappa values.
Results: The statistical analysis indicates a good intraobserver agreement (unweighted kappa values
0.77 and 0.64) and a moderate or fair interobserver agreement (unweighted kappa values 0.51 and
0.42).
Conclusion: The good intraobserver agreement indicates that consistent evaluation of the
assessment is possible. The lower interobserver agreement reflects individual differences in
diagnostic decision-making, and that education is needed to achieve uniform reading.
In summary: MR-imaging can be used for assessment of hemophilic arthropathy. Evaluation of the
investigations by specially trained radiologists is mandatory.
126
th
Saturday, 14th June, 10.30 – 12.00 a.m. – Trauma and miscellaneous – Session 6b
Chair: K. Jonsson (SE), S. Andersson (CH)
Abstract no. 125
CT FOR EVALUATION OF ROTATIONAL DISLOCATION IN SUPRACONDYLAR ELBOW
FRACTURES
K. Jonsson, C. Adlercreutz, M. Enekvist
Center for Imaging and Physiology, University Hospital, S-221 85 Lund, Sweden
Aim: To describe the use of CT for evaluation of rotational dislocation in supracondylar elbow
fractures.
Patíents and Methods: We have examined 7 children, 4 girls and 3 boys, aged 5 - 11, mean 7,5
years. In most cases the patients have been examined supine, with the forearm on the abdomen.
Thin CT sections over the humeral shaft and the supracondylar fragment have been obtained. The
rotational dislocation has been assessed as the difference between the angulations of the two
fragments in relation to the table plane.
Results: It is easy to assess the rotational dislocation by means of CT, both in plaster and
postoperatively after pinning of the fracture.
Conclusions: If a supracondylar fracture heals with rotational dislocation of more than 15 degrees
there is great risk for varus deformity of the elbow. This complication can be avoided if correct
degree of dislocation is determined to indicate surgical treatment.
Abstract no. 126
MRI IN PEDIATRIC ELBOW TRAUMA
T. Pudas, S. Erkki, H. Timo, M. Kimmo
Depts. of Diagnostic Radiology and Pediatric Surgery, University of Turku, 20520 Turku, Finland
Aim: Pediatric elbow traumas with joint effusion are problematic. We used MRI without sedation
to further evaluate these patients.
Patients and methods:
The study group consisted of 26 children (mean age 7,6 years) with elbow injury. The plain films
showed supracondylar fractures (10), lateral condyle fractures (7) and one proximal radial head
fracture. Eight patients had elbow effusion with no detectable fracture on the radiographs. MR
imaging was performed with the elbow in cast using 0,23 T open configuration MR imager.
Results: MR imaging showed 4 occult elbow fractures in patients with no visible fracture on
radiographs. All 10 supracondylar fractures showed at MRI besides the fracture line also extensive
bone marrow edema in distal humerus and also in 9 patients in proximal ulna. One radiographically
intra-articular fracture turned to be extra-articular and one supracondylar fracture was intercondylar
127
fracture in MRI. Two patients had ruptured anterior joint capsule. In 7 radiographical lateral
condyle fractures one turned to be supracondylar and in three patients there was more than 2 mm
discrepancy of the articular cartilage.
Conclusion: MRI changed the diagnosis of seven patients. MRI selected patients needed more
intensive clinical follow up and patients that were considered for operative treatment.
Abstact no. 127
MR IMAGING OF AVASCULAR SCAPHOID NONUNION AFTER VASCULARIZED BONE
GRAFTING
S.E. Anderson1, L.S. Steinbach2, M. Martin1, D. Tschering-Vogel1, L. Nagy3
Dept. of Radiology, University Hospital of Bern, Bern, Switzerland
Purpose: Our purpose was to investigate the MR imaging appearances of chronic nonunion of the
scaphoid with proximal pole avascular necrosis before and after insertion of a vascularized bone
graft.
Materials and Methods: 13 men with chronic scaphoid nonunion and proximal pole avascular
necrosis were evaluated. MR imaging (n: 26), computerized tomography (n: 13) and radiographs (n:
52) were performed. The presence of avascular necrosis of scaphoid proximal pole was confirmed
intra-operatively in all patients. Images were performed preoperatively and following placement of
vascularized bone graft. Scaphoid MR signal characteristics were assessed with review for evidence
of vascular bone graft marrow incorporation with revascularization of proximal pole of scaphoid.
Surgical and clinical notes were reviewed with a minimum four year imaging and clinical follow-up
in all patients.
Results: Graft incorporation with revascularization of proximal pole of scaphoid was documented
in 9 patients (69.2%). Graft failure with persistence pseudoarthrosis of scaphoid was seen in 4
patients (30.7%).
Conclusions: MR imaging is useful to determine whether vascularized bone graft incorporation has
occurred in the setting of avascular scaphoid nonunion.
Abstract no. 128
MINIMISING DOSE IN LUMBAR SPINE RADIOGRAPHS AN AUDIT
D.H. Taylor, N. Pathirana.
Dept. of Radiology, The Ulster Hospital Dundonald, Belfast, Northern Ireland
Aims: Lumbar spine radiography is a frequently performed high dose examination.
Optimal lowest dose technique is desirable. This study compared current practice to published
standards. It assessed the need for and recommended change, aiming to reduce patient doses.
Methods: The choice of a left lateral and a caudally directed anode (for female patients) were used
as the published standards of lowest effective dose technique.
128
All adult patients referred for lumbar spine radiography in this institution during a prospective 10
day period were included. The choice of lateral and the direction of the anode were recorded on
request cards by radiographers. These cards were then retrospectively analysed. An identical
reaudit was performed 3 months later.
Results: Of a total of 66 patients, 42 % underwent a right lateral. In 12% the anode faced the head.
After the study recommendations to adopt the proposed standard were communicated in a
presentation to the radiography staff. Reaudit confirmed persisting practice of the new standard
with significant reduction in the numbers of right laterals being performed.
Conclusions: Significant reduction in effective dose is achievable by minor and sustainable
changes in radiographic practice.
Abstract no. 129
3D VISUALIZATION OF CT SCANS ON A HANDHELD POCKET COMPUTER, IS IT A
REALITY?
H.E. Gregersen
Dept. of Radiology, Aalborg Hospital, Aalborg, Denmark
In Aalborg Hospital, we have installed an image communication system, that allows the end user
(clinician) to perform 3D and volume reconstruction on line and in real time, on any computer in
the enterprise, including handheld Pocket computers (PDA). The system is based on an open
platform cluster server that allows any user to get direct access to all patient information, without
need to have access to a workstation. The system is to our knowledge the only one to have these
properties.
129
Posters, presented at Room 11 and 12
th
Presentation/Discussion in Room 12, Saturday, 14th June, 1.00 – 2.30 p.m.
Abstract no. 130
ULTRASOUND IMAGING OF JOINT DISEASE
C. Groves 2, P.J. O’Connor1, A.J. Grainger1
Dept. of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, NHS Trust, Leeds1, Oswestry 2,
UK
E-mail: mailto:[email protected]
The aim of the poster is to give the reader a clearer understanding of the type of abnormality
ultrasound can demonstrate in arthropathy and how the findings can influence patient management.
We present an overview of the role of ultrasound in the assessment of joint disease detailing with
the technical aspects of performing joint ultrasound, the interpretation of imaging findings and
reviewing the relevant literature regarding diagnostic and therapeutic impact in three main areas:
1. Synovitis
2. Erosion
3. Enthesitis
To clinicians and radiologists, ultrasound offers many advantages over MRI in the assessment of
joint pathology. It is a readily available multiplanar soft-tissue imaging modality that is portable and
can be employed easily within, or close to the outpatient clinic and allows multiple site assessment.
Scanning involves a rapid dynamic assessment of joints and their peri-articular structures giving
both anatomical and functional elements to the ultrasound examination.
Abstract no. 131
COSTAL CHONDROID TUMORS MIMICKING INTRA-ABDOMINAL MASSES.
RADIOLOGICAL AND PATHOLOGICAL CORRELATION
X. Tomás-Batlle, A.E. Cores, J. Pomés, C. Mallofré*, A.I. García-Díez, P. Arguis, I. Aguirre.
Radiology (CDIC) and Pathology* Dpt. Hospital Clínic. Villarroel 170. Barcelona, Spain
Purpose: To describe radiologic features and pathological correlation of chondroid tumors arising
from rib cage into abdominal upper right quadrant.
Patient and Methods: 3 patients (2M and 1F, aged from 50 to 71 yr.) with an abdominal anterior
wall mass underwent CT scanning. CT guided percutaneous fine needle puncture (PFNP) was
performed in 2 cases. Medical records were reviewed.
Results: Using pathological criteria 1 chondroma and 2 chondrosarcomas were diagnosed. CT
findings included a soft heterogeneous tissue mass arising from rib cage into abdominal upper right
quadrant, with liver displacement. Lesions size ranged from 7.5 cm to 9.5 cm. Chondroid
calcifications were present. There were signs of huge liver contact. Aggressive bone lysis and ill
define margins were seen in the 2 chondrosarcomas. PFNPs were true positive for chondroid
tumors, but could not set their malignant nature.
Conclusions: Costal, chondroid tumors may mimic abdominal upper right quadrant masses. CT is
useful for making a presumptive diagnosis of their chondroid nature and as a tool for PFNP.
130
However, there is an overlap in the radiological and cytological appearance of benign and
malignant lesions. It suggests that radical surgery is the appropiate treatment in these patients.
Abstract no. 132
THE USE OF MRI IN DIAGNOSIS OF OCCULT HIP FRACTURES: A PRELIMINARY
REVIEW
L.F. Foo, A.W. Forrester
Dept. of Radiology, Glasgow Royal Infirmery, Glasgow, UK
Purpose: Traditionally the diagnosis of an occult hip fracture is made on the basis of clinical
findings, further observation, repeat plain films, tomography or isotope bone scan. Our aim is to
demonstrate the usefulness of MRI in diagnosis of occult hip fractures and also define a referral
algorithm for its use.
Patients and Methods: During 27 months a total of 11 patients clinically suspected of a post
traumatic occult hip fracture were evaluated with MRI after review by a senior Orthopaedic
Consultant Surgeon. All examinations were performed on 1.5T Phillips Gyroscan ACS-NT on the
day of referral. T1-W SE and STIR sequences were performed in both axial and coronal planes.
Results were then compared to clinical outcome.
Results: Fractures were demonstrated in 10 cases. The site and anatomical extent of fractures were
well defined by MRI, as were associated soft tissue injuries. In one case with no fracture, the cause
for hip pain was identified as muscle oedema over the greater trochanter.
An incidental finding of a vascular necrosis was demonstrated in one case, on the asymptomatic
side.
All patients received definitive treatment within 24 hours. In those treated surgically, MRI findings
helped determine the type of operative fixation.
Early mobilization was encouraged in those treated conservatively.
Conclusion: MRI is a rapid, non-invasive and accurate imaging modality in the early diagnosis of
occult hip fracture. It is also useful in identifying non fracture causes of pain and incidental lesions.
It allows for early definitive treatment for all patients. Limiting referrals to requests from
Consultant Orthopaedic Surgeons resulted in a high diagnostic yield.
Abstract no. 133
DIFFERENTIAL DIAGNOSTIC APPROACH OF CRMO: CHRONIC RECURRENT
MULTIPLEX OSTEOMYELITIS
K. Kollo, A.R. Mester, K. Karlinger, P.N. Kaposi
Dept. of Orthopaedic Surgery. Dept. of Diagnostic Radiology and Oncotherapy.
Faculty of Medicine, Semmelweis University, Budapest
MRI Centre of National Institute for Rheumatology and Physiotherapy, Budapest
Aim of the study is a demonstration of a relative rare disease: CRMO (chronic recurrent multiplex
osteomyelitis) with special emphasis to differential diagnostic approach included OCD
(osteochondritis dissecans) in one of the two cases.
131
Methods and study design: Plain film radiography, CT and MRI studies were evaluated.
Case 1: one year old infant with recurrent metaphyseal lesion of right tibia and of right radius. Mild
osteomyelitis was found by biopsy without bacteria. Case 2: Plain films of an eleven years old male
patient with lytic distal metaphyseal lesion of the left radius suggested either Ewing sarcoma or
Langerhans cell histiocytosis (LCH). Osteomyelitis without bacteria was the biopsy result. The
patient got knee pain in a month. The HRCT (high resolution CT) showed OCD (osteochondritis
dissecans) and a metaphyseal partially lytic and partially sclerotic lesion as well.
Results: New observation was the coexistence of CRMO and OCD, where the OCD was the
dominant HRCT morphological symptom, but the pain was related to CRMO. In the literature
Giedion published (1972) first CRMO. Differential diagnostic alternatives, like malignancies, LCH,
osteoid osteoma versus bacterial osteomyelitis published others.
Conclusion: Complex imaging of OCD and CRMO in adjacent localisation offers new aspects of
differential diagnosis.
Abstract no. 134
PICTORIAL REVIEW OF DIAGNOSIS IMAGING TECHNIQUES IN FOLLOWING-UP HIP
ARTHROPLASTIES
P. Melloni Ribas
Dept. of UDIAT – Centre Diagnòstic, Sabadell, (Barcelona), Spain
Purpose: The purpose of this study was to evaluate the spectrum of plain radiographic and other
imaging techniques findings in patients with early or lately complications of hip prostheses. We
describe the utility of each imaging techniques for following-up them.
Material and Methods: Each year more of 200 hip prosthesis were realized in our hospital, since
14 years ago. All patients were controlled immediately after surgery, at 6 months and then yearly or
when necessary, by plain films and sometimes sonography and/or computerized tomography. US
and CT were used to confirm or reject osteointegration of the prosthesis and complications such as
periprothesic abscess and/or hematoma.
Results: We analysed radiological features of the normal and pathological evolution of hip
prosthesis. And we describe early complications, such as infection, cement extrusion, and
periprosthesic fracture, that were presented in 5,2%. And lately complications, such as aseptic
loosening, osteolytic lesions, heterotopic calcifications, migration of the acetabular component,
femoral diaphysis fracture, dislocation of the prosthesis, appeared in 9% of the patients.
Conclusion: Plain films are essential for evaluation and detection of hip arthroplasties. US is
usually used to guide percutaneous aspiration of soft tissue collection. And CT provides a correct
assessment of the osteointegration of hip prosthesis.
132
Abstract no. 135
ABDOMINAL METASTASES ARISING FROM BONE SARCOMAS: REPORT OF FOUR
PATIENTS
J.Y. Kim, K.A. Chun, J.M. Park, Y.H. Park
Dept. of Radiology, St. Vincent’s Hospital, The Catholoic University of Korea, South Korea
We report four unusual cases of abdominal metastases arising from a primary bone sarcoma. In
those primary tumors forming bone or cartilage, metastatic lesions often have similar
characteristics. Although abdominal metastases from bone sarcoma are rare, characteristic
calcifications of metastatic masses may provide an important diagnostic clue. In our cases,
metastases occurred in peritoneum, abdominal wall muscles, gallbladder, and pancreas. A review of
the literature and possible pathophysiological mechanisms are discussed.
Abstract no. 136
REGIONAL BLOCK IN LOWER-LIMB: VALUE OF IMAGING TECHNIQUES.
J.T. Pomés, A.I. García-Diez, X. Tomás, X. Sala*, X Bargalló, S Massaguer, T Pujol.
Dept. of Radiology (CDIC) and Anaesthesiology*, Hospital Clínic, Barcelona, Spain
Purpose: To show the value of computed tomography, ultrasonography, uadiographs and magnetic
resonance imaging for the regional block in lower-limb.
Patients and Methods: We review the different approaches in regional anaesthesia and
postoperative pain relief techniques in lower-limb. We reproduce the procedure position with
imaging techniques to show the anatomical relations and its changes with minimal variations. We
also present the distribution of the local anaesthetic.
Results: The median location depth for the approach to the block was: 7 cm for the lumbar plexus
posterior approach, 7 cm for the femoral nerve paravascular approach, 2 cm for the pubic tubercle
approach to the obturator nerve block, 7 cm to the three-in-one block (femoral, lateral femoral
cutaneous and obturator nerves), 4.5 cm for the sciatic nerve posterior approach, 10 cm for the
sciatic nerve anterior approach, 4 cm for the popliteal nerve intertendinous approach and 5 cm for
the popliteal nerve lateral approach.
Conclusion: A nerve stimulation-guided feasibility the needle or catheter placement, unfortunately,
not provides a visualization of anatomy. Imaging techniques improve the quality of sensory block
and minimizes risks, also help to understand the influence of different approaches and distribution
of the local anaesthetic.
Abstract no. 137
MUSCULOSKELETAL HEMANGIOMA FROM HEAD TO TOE - MR IMAGING WITH
PATHOLOGIC CORRELATION
JC Vilanova*, J Barceló*, R. Pérez-Andrés***. M. Villalón*, J.Miró*
*Clínica Girona. Girona. **Hospital Universitari “Germans Trias i Pujol”. Badalona. Spain
133
Purpose: Illustrate the MRI and MRA characteristics of hemangioma from the whole body with
pathologic correlation.
Material and Methods: MRI sequences and MR angiography (MRA) techniques have been used to
illustrate and characterize vascular tumors from head to toe with pathologic correlation.
Results: Hemangiomas are vascular tumors, which can be found relatively common in the
musculoskeletal system. MRI/MRA allows characterizing hemangioma when the features are
typical.
Soft tissue hemangiomas appear, from head to toe, when typical as multiple lobules of high signal
on T2 with serpentine structures, isointense on T1 with areas of fat, fibrosis, thrombosis, phlebolits.
Bone hemangioma appears as a high signal trabecular pattern on T1 and T2 or multifocal lytic areas
creating a honeycomb pattern.
Hemangioendothelioma, hemangiopericytoma and glomus are more aggresive vascular neoplasms
with a nonspecific MR appearance.
Conclusion: MRI and MRA characteristics of hemangioma from the whole body allows to perform
a more specific diagnosis, evaluation and better assessment of vascular tumors
Abstract no 138
ANTERIOR CRUCIATE LIGAMENT TEAR-ASSOCIATED INJURIES AT MR IMAGING
G. Mantzikopoulos, K. Pikoulas, I. Staikidou, G. Giannikouris, K. Dagaida
Radiological Imaging Department 1st IKA & KAT Hospitals, Athens, Greece
Purpose: To investigate the frequency and degree of anterior cruciate ligament (ACL) tearsassociated knee injuries.
Material and Methods: Prospective evaluation of 180 consecutive patients with documented
complete ACL tears was performed. They were classified as acute (n=113) and chronic (n=67) tears
(9 weeks from injury as a criterion).
Results: In acute and chronic ACL tears, associated injuries were respectively: Bone bruises: 92%
(104) and 28% (19). Tibial plateau or femoral condyle fractures: 14% (16) and 6% (4). MCL grade
I: 23% (26) and 9% (6), grade II: 9.7% (11) and 12% (8), grade III: 12% (14) and 3% (2). Medial
meniscus tear: 39% (44) and 58% (39).
Lateral meniscus tear: 30% (34) and 28% (19). PCL tear: 6% (7) and 1.5% (1). LCL injuries were
found only in the acute setting: grade I 3.5% (4), grade II 2.6% (3), grade III 3.5% (4). Bucket
Handle tears were 7.7% (6 of 78 tears) in acute ACL tears and 13.8% (8 of 58 tears) in chronic ACL
tears. In chronic ACL tears there were 22 cases (33%) with osteoarthritic changes, 2 (3%) with
femoral condyle osteonecrosis.
Conclusion: MRI is an important tool in formulating treatment options in patients with ACL tears
since it detects various associated injuries, difficult to appreciate on physical examination width
have major impact on clinical management.
134
Abstract no. 139
CT-GUIDED PERCUTANEOUS BIOPSY OF FOCAL LESIONS IN THE THORACIC SPINE
PRESENTING A LIMITED ACCESS ROUTE
G. Mantzikopoulos, K. Pikoulas, G. Giannikouris, I. Staikidou, K. Dagaida
Radiological Imaging Department 1st IKA & KAT Hospitals, Athens, Greece
Purpose: To present the experience of our department in the selection of cases and the technique of
CT guided percutaneous biopsy of focal lesions in the thoracic spine, which present with a limited
access route.
Material and Methods: 36 patients (22 men and 14 women) who had a percutaneous CT guided
biopsy of a focal thoracic spine lesion in our department during the last 2 years. These cases
presented either with pathologic paravertebral soft tissue of limited extend anterolaterally or with a
lytic lesion confined to the vertebra with a bone margin that could be safely penetrated. We used
18G and 20G Franseen and Quick Core biopsy needles, with a direct or a coaxial placement
technique. In 8 cases expansion of the extrapleural space with normal saline injection was
performed.
Results: All biopsies yielded diagnostic material. 17 cases had metastatic lesions, 4 cases had
plasmocytoma and 15 had inflammatory lesions. There were no complications.
Conclusion: CT guided percutaneous biopsy of focal lesions in the thoracic spine is a safe
procedure with a high success rate.
Abstract no. 140
RETROSPECTIVE ANALYSIS OF ULTRASOUND GUIDED CORE BIOPSY IN THE
DIAGNOSIS OF SOFT TISSUE MASSES
F.J. Perks, I. Beggs, J.O’Neill
Dept of Radiology, Royal Infirmary of Edinburgh, Edinburgh, Scotland
Aims/purpose: To assess the accuracy of ultrasound guided core biopsy of soft tissue masses.
Patients and Methods: We reviewed 66 soft tissue biopsies in 63 consecutive patients. Diagnoses
were compared to the post excision diagnosis in 28 patients. All core biopsies were performed by
the same radiologist using ultrasound guidance. Biopsies were performed as outpatient procedures.
Results: 3 biopsies were repeated. 56 (85%) biopsies were diagnostic of a wide range of benign and
malignant disease. 26 of 28 (93%) biopsies were accurately representative of post excision
histology. 27 biopsies diagnosed disease that did not warrant excision. Significant pathology was
excluded by biopsy in 7 patients. Overall sensitivity and specificity was 95% and 100%
respectively. There were no complications.
Conclusions: Ultrasound guided core biopsy yields a representative tissue sample permitting
accurate tissue diagnosis. The technique is time and cost effective and carries a negligible
complication rate.
135
Bone Densitometry Workshop
Abstract B
RADIOGRAPHICAL FEATURES OF OSTEOPOROSIS
Wilfred C.G. Peh, MBBS, MD, FRCPG, FRCPE, FRCR
Senior Consultant Radiologist, Singapore Health Services
Clinical Professor, National University of Singapore
Email: [email protected]
Osteoporosis is characterised by qualitatively normal but quantitatively deficient bone. It may be
classified into generalised or regional osteoporosis. Generalised osteoporosis involves the entire
skeleton and may be due to numerous aetiologies, with senile osteoporosis being the most common
cause. The radiological appearances of osteoporosis are essentially similar, irrespective of cause.
Despite the availability of newer and more expensive imaging modalities, osteoporosis is probably
best diagnosed on conventional radiographs although early disease is better detected and assessed
using quantitative techniques.
The main radiographical features of osteoporosis are increased radiolucency and cortical thinning.
Increased radiolucency or osteopenia is due to trabecular thinning and resorption. With initial
involvement of the secondary trabeculae, the primary trabeculae develop relative prominence. In the
spine, a striated appearance is produced. Radiographs are relatively insensitive for detecting early
changes of osteopenia as approximately 30% of bone loss must occur before it can be detected.
Cortical thinning is due to osseous resorption in the cortex. Intracortical resorption may give rise to
cortical tunnelling. Predominance of type of resorption, e.g. endosteal or subperiosteal, may
provide a clue to the cause of bone resorption. Despite cortical thinning, the cortex usually remains
sharp and clear.
The changes of generalised osteoporosis are typically most apparent in the axial skeleton and the
proximal ends of long bones. Fractures are an important complication of osteoporosis and
commonly involve the spine, proximal femur, distal radius and humeral neck. Insufficiency
fractures are a well-recognised subgroup of osteoporotic fractures. The main differential diagnoses
of generalised osteoporosis are other conditions that can cause diffuse osteopenia. In the spine,
being able to distinguish osteoporotic vertebral fractures from malignant fractures is important.
Regional osteoporosis involves only part of the skeleton and is less commonly encountered than
generalised osteoporosis. Causes of regional osteoporosis include disuse osteoporosis, reflex
sympathetic dystrophy, transient osteoporosis of the hip and periarticular osteoporosis associated
with arthropathy. Knowledge of clinical findings helps in the radiographical diagnosis.
Reference
Quek ST, Peh WCG. Radiology of Osteoporosis. Semin Musculoskeletal Radiol 2002;6:197-206.
136
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137

Abstracts Programme 2003

Transcription

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