Role of MR imaging in chronic wrist pain

Magnetic resonance (MR) imaging for chronic wrist pain is challenging. Correct assessment of the triangular fibrocartilage, hyaline cartilage, ligaments, and tendons has become mandatory for comprehensive decision making in wrist surgery. The MR technique, potential and limits of MR imaging in patients with chronic wrist pain will be discussed. MR arthrography with injection of gadolinium-containing contrast material into the distal radioulnar joint is suggested for evaluation of the triangular fibrocartilage. The clinically meaningful ulnar-sided peripheral tears are otherwise hard to diagnose. The diagnostic performance of MR imaging for interosseous ligament tears varies considerably. The sensitivity for scapholunate ligament tears is consistently better than for lunotriquetral ligament tears. Gadolinium-enhanced MR imaging is considered to be the best technique for detecting established avascularity of bone, but the assessment of the MR results remains challenging. Most cases of ulnar impaction syndrome have characteristic focal signal intensity changes in the ulnar aspect of the lunate. Avascular necrosis of the lunate (Kienböck's disease) is characterized by signal changes starting in the proximal radial aspect of the lunate. MR imaging is extremely sensitive for occult fractures. Questions arise if occult posttraumatic bone lesions seen on MR images only necessarily require the same treatment as fractures evident on plain films or computed tomography (CT) images. MR imaging and ultrasound are equally effective for detecting occult carpal ganglia. Carpe bossu (carpal boss) is a bony protuberance of a carpometacarpal joint II and III which may be associated with pai

Detection and quantification of glenohumeral joint effusion: reliability of ultrasound

Objectives: To evaluate reliability of ultrasound for detection and quantification of glenohumeral joint effusion. Methods: With institutional review board approval and informed consent ultrasound of 30 consecutive patients before and after MR arthrography of the shoulder was performed. Presence and width of any anechoic collection was noted within various locations (biceps tendon sheath, subscapular recess (neutral position and internal rotation), posterior glenohumeral joint recess (neutral position and external rotation)). Injected fluid (8-12ml) into the glenohumeral joint served as gold-standard. Widths of anechoic collections were correlated (Spearman rank correlation) with injected fluid. Results: Glenohumeral anechoic collection was consistently seen in the posterior glenohumeral joint recess with the arm in external rotation (100%, 30/30), and in the biceps tendon sheath (97%, 29/30). Ultrasound was not sensitive at other locations (7%-17%). Mean width in anterior-posterior direction of anechoic collection in the posterior glenohumeral joint recess was 7mm (range: 3-18mm), 2mm (range: 1-7mm) in the biceps tendon sheath. Significant correlation (R = 0.390, p = 0.033) was found between width of anechoic collection and injected fluid in the posterior glenohumeral joint recess. Conclusions: Glenohumeral joint effusion can be detected and quantified most reliably in the posterior glenohumeral joint recess with the arm in external rotatio

Closed suction drainage with or without re-transfusion of filtered shed blood does not offer advantages in primary non-cemented total hip replacement using a direct anterior approach

Introduction: Wondering if the use of drains allowing re-transfusion of shed blood as opposed to closed suction drains or no drains would improve quality of care to patients undergoing simple non-cemented primary total hip replacement (THR) using a direct anterior approach, a three-arm prospective randomized study was conducted. Method: One hundred and twenty patients were prospectively randomized to receive no drain, closed suction drains or drains designed for re-transfusion of shed blood. Blood loss, VAS pain scores, thigh swelling, hematoma formation, number of dressings changed and hospital stay were compared and patients followed for 3months. Results: Drains did not have any significance on postoperative haemoglobin and haematocrit levels or homologous blood transfusion rates. Patients receiving homologous blood transfusions had too small drain volumes to benefit from re-transfusion and patients, who get drained fluid re-transfused, were far away from being in need of homologous blood transfusion. Omitting drains resulted in more thigh swelling accompanied with a tendency of slightly more pain during the first postoperative day but without effect on clinical and radiological outcome at 3months. Earlier dry operation sites resulting in simplified wound care and shorter hospital stay was encountered when no drain was used. Conclusion: The possibility to re-transfuse drained blood was not an argument for using drains and, accepting more thigh swelling, we stop to use drains in simple non-cemented primary THR using the direct anterior approac

Articular cartilage and labral lesions of the glenohumeral joint: diagnostic performance of 3D water-excitation true FISP MR arthrography

Objective: To evaluate the diagnostic performance of MR arthrography in the detection of articular cartilage and labral lesions of the glenohumeral joint using a transverse 3D water-excitation true fast imaging with steady-state precession (FISP) sequence. Materials and Methods: Seventy-five shoulders were included retrospectively. Shoulder arthroscopy was performed within 6months of MR arthrography. MR images were evaluated separately by two radiologists. They were blinded to clinical and arthroscopic information. Arthroscopy served as the reference standard. Results: For the detection of humeral cartilage lesions, sensitivities and specificities were 86% (12/14)/89% (50/56) for observer 1 and 93%/86% for observer 2) for the transverse true FISP sequence and 64%/86% (50%/82% for observer 2) for the coronal intermediate-weighted spin-echo images. The corresponding values for the glenoidal cartilage were 60% (6/10)/88% (51/58) (80%/76% for observer 2) and 70%/86% (60%/74% for observer 2) respectively. For the detection of abnormalities of the anterior labrum (only assessed on true FISP images) the values were 94% (15/16)/84% (36/43) (88%/79% for observer 2). The corresponding values for the posterior labrum were 67% (8/12)/77% (36/47) (observer 2: 25%/74%). The kappa values for the grading of the humeral and glenoidal cartilage lesions were 0.81 and 0.55 for true FISP images compared with 0.49 and 0.43 for intermediate-weighted fast spin-echo images. Kappa values for true FISP evaluation of the anterior and posterior part of the labrum were 0.81 and 0.70. Conclusion: Transverse 3D true FISP MR arthrography images are useful for the difficult diagnosis of glenohumeral cartilage lesions and suitable for detecting labral abnormalitie

Is the Internal Rotation Lag Sign a Sensitive Test for Detecting Hip Abductor Tendon Ruptures after Total Hip Arthroplasty?

INTRODUCTION: Total hip arthroplasty (THA) is one of the most frequently performed procedures in orthopaedics and weakness of external rotators is often recognized thereafter. However, the etiology of lateral hip pain is multifaceted. For the diagnosis of abductor tendon rupture, magnetic resonance imaging (MRI) is the gold standard. As not every patient can be subjected to MRI, a clinical diagnostic test for easy detection of lesions of the abductor tendon is missing. Here, we present the internal rotation lack sign indicating abductor tendon pathology. METHODS: The patient is placed in lateral position on a stretcher with hips and knees in neutral position. The knee is flexed to 45° and the hip passively abducted and elevated by the investigator. With the foot passively abducted, the patient is then asked to bring his knee in direction to the examination table. This motion is also tested passively. The test is regarded positive, if no internal rotation is possible and/or if this is painful. If groin pain is elicited during either of the exercises, the test is also rated positive. RESULTS: We evaluated this test in 20 patients clinically and by magnetic resonance imaging (MRI). All patients demonstrated a positive internal rotation lag sign. Twelve of them lag of internal rotation and evidence of anterior abductor tendon rupture on MRI, 8 with lag of internal rotation and no evidence of abductor tendon rupture. CONCLUSION: The new clinical diagnostic sign presented here may improve the diagnosis of abductor tendon rupture in the future.Level of Evidence: Diagnostic study, level I

Diagnostic performance of MRI measurements to assess hindfoot malalignment. An assessment of four measurement techniques

Objective: To investigate the ability of coronal non-weight-bearing MR images to discriminate between normal and abnormal hindfoot alignment. Methods: Three different measurement techniques (calcaneal axis, medial/lateral calcaneal contour) based on weight-bearing hindfoot alignment radiographs were applied in 49 patients (mean, 48years; range 21-76years). Three groups of subjects were enrolled: (1) normal hindfoot alignment (0°-10° valgus); (2) abnormal valgus (>10°); (3) any degree of varus hindfoot alignment. Hindfoot alignment was then measured on coronal MR images using four different measurement techniques (calcaneal axis, medial/lateral calcaneal contour, sustentaculum tangent). ROC analysis was performed to find the MR measurement with the greatest sensitivity and specificity for discrimination between normal and abnormal hindfoot alignment. Results: The most accurate measurement on MR images to detect abnormal hindfoot valgus was the one using the medial calcaneal contour, reaching a sensitivity/specificity of 86%/75% using a cutoff value of >11° valgus. The most accurate measurement on MR images to detect abnormal hindfoot varus was the sustentaculum tangent, reaching a sensitivity/specificity of 91%/71% using a cutoff value of <12° valgus. Conclusion: It is possible to suspect abnormal hindfoot alignment on coronal non-weight-bearing MR images. Key Points : • Abnormal hindfoot alignment can be identified on coronal non-weight-bearing MR images. • The sustentaculum tangent was the best predictor of an abnormally varus hindfoot. • The medial calcaneal contour was the best predictor of a valgus hindfoo

Role of MR imaging in chronic wrist pain

Magnetic resonance (MR) imaging for chronic wrist pain is challenging. Correct assessment of the triangular fibrocartilage, hyaline cartilage, ligaments, and tendons has become mandatory for comprehensive decision making in wrist surgery. The MR technique, potential and limits of MR imaging in patients with chronic wrist pain will be discussed. MR arthrography with injection of gadolinium-containing contrast material into the distal radioulnar joint is suggested for evaluation of the triangular fibrocartilage. The clinically meaningful ulnar-sided peripheral tears are otherwise hard to diagnose. The diagnostic performance of MR imaging for interosseous ligament tears varies considerably. The sensitivity for scapholunate ligament tears is consistently better than for lunotriquetral ligament tears. Gadolinium-enhanced MR imaging is considered to be the best technique for detecting established avascularity of bone, but the assessment of the MR results remains challenging. Most cases of ulnar impaction syndrome have characteristic focal signal intensity changes in the ulnar aspect of the lunate. Avascular necrosis of the lunate (Kienböck's disease) is characterized by signal changes starting in the proximal radial aspect of the lunate. MR imaging is extremely sensitive for occult fractures. Questions arise if occult posttraumatic bone lesions seen on MR images only necessarily require the same treatment as fractures evident on plain films or computed tomography (CT) images. MR imaging and ultrasound are equally effective for detecting occult carpal ganglia. Carpe bossu (carpal boss) is a bony protuberance of a carpometacarpal joint II and III which may be associated with pai

Good correlation of goutallier rating of supraspinatus fatty changes on axial and reformatted parasagittal computed tomographic images

UNLABELLED Traumatic tendon tear of the rotator cuff occurs frequently and leads to fatty muscle infiltration. With regard to the outcome, fatty infiltration of the rotator cuff muscles constitutes a major negative predictive factor after rotator cuff surgery. In 1989, Goutallier et al established his classification system for assessment of fatty infiltration of the rotator cuff muscles. He used computed tomographic (CT) images in the axial plane. Today, the assessment of rotator cuff muscles on axial CT images has been widely replaced by assessment on parasagittal acquired magnetic resonance images. This change raised 2 important questions. First, there is a controversy whether the Goutallier classification can simply be adopted for magnetic resonance imaging. The second question is whether the muscle assessment in the axial plane is interchangeable with that in the parasagittal plane. We hypothesize that the assessment of fatty muscle infiltration is the same on reformatted parasagittal CT images as on axial CT images METHODS Three independent readers, 2 radiologists and one shoulder surgeon, rated fatty changes of the supraspinatus muscle on CT scans of 91 shoulders. Goutallier grades were assessed on axial and reformatted parasagittal CT images in 2 separate reading sessions. The paired t test was used to find differences between grading results on axial and reformatted parasagittal images. The Pearson correlation coefficient and weighted kappa statistics were used to quantify linear correlation, intrareader, and interreader agreement. RESULTS Mean (SD) Goutallier grading among all readers was 0.80 (1.16) (range, 0-4) on axial images and 0.89 (1.05) (range, 004) on parasagittal reconstructions. We detected a trend toward a slightly higher Goutallier grading on parasagittal reconstructions; however, this result was not significant (P = 0.07). The Pearson correlation coefficient was 0.702 (P < 0.001). Weighted kappa statistics indicated a moderately good to good intrareader (range of weighted kappa, 0.53-0.62) and interreader (weighted kappa, axial images, 0.55; reformatted parasagittal images, 0.65) agreement. CONCLUSION Grading of fatty infiltration of the supraspinatus muscle on parasagittal CT images is comparable with the standard Goutallier grading on axial images and is characterized by a moderately good to good intrareader and interreader agreement. Assessment of parasagittal images is characterized by a slightly higher interreader agreement and may therefore be the preferable modality

Is there an added value of T1-weighted contrast-enhanced fat-suppressed spin-echo MR sequences compared to STIR sequences in MRI of the foot and ankle?

OBJECTIVES To prospectively compare T1-weighted fat-suppressed spin-echo magnetic resonance (MR) sequences after gadolinium application (T1wGdFS) to STIR sequences in patients with acute and chronic foot pain. METHODS In 51 patients referred for MRI of the foot and ankle, additional transverse and sagittal T1wGdFS sequences were obtained. Two sets of MR images (standard protocol with STIR or T1wGdFS) were analysed. Diagnosis, diagnostic confidence, and localization of the abnormality were noted. Standard of reference was established by an expert panel of two experienced MSK radiologists and one experienced foot surgeon based on MR images, clinical charts and surgical reports. Patients reported prospectively localization of pain. Descriptive statistics, McNemar test and Kappa test were used. RESULTS Diagnostic accuracy with STIR protocol was 80% for reader 1, 67% for reader 2, with contrast-protocol 84%, both readers. Significance was found for reader 2. Diagnostic confidence for reader 1 was 1.7 with STIR, 1.3 with contrast-protocol; reader 2: 2.1/1.7. Significance was found for reader 1. Pain location correlated with STIR sequences in 64% and 52%, with gadolinium sequences in 70% and 71%. CONCLUSIONS T1-weighted contrast material-enhanced fat-suppressed spin-echo magnetic resonance sequences improve diagnostic accuracy, diagnostic confidence and correlation of MR abnormalities with pain location in MRI of the foot and ankle. However, the additional value is small. KEY POINTS • Additional value of contrast-enhanced MR over standard MR with STIR sequences exists. • There is slightly more added value for soft tissue than for bony lesions. • This added value is limited. • Therefore, application of contrast material cannot be generally recommended