Quantitative Evaluation of the Tibial Tunnel after Intraoperatively Locally Administered Platelet Rich Plasma Gel during Anterior Cruciate Ligament Reconstruction Using Diffusion Weighted and Dynamic Contrast-Enhanced MRI

Ozadje. Raztrganina sprednje križne vezi (Anterior cruciate ligament, ACL) spada med najpogostejše poškodbe kolena. Po rekonstrukciji je zaradi počasnega vraščanja in ligamentizacije presadka rehabilitacija dolgotrajna. Z namenom pospešiti vraščanje potekajo študije različnih modifikacij rekonstrukcije, v zadnjem desetletju najpogosteje z lokalno apliciranim trombocitnim gelom (TG, Platelet rich plasma gel, PRPG) kot nosilcem različnih rastnih faktorjev (RF). Zaradi etičnih in tehničnih razlogov je histološko ugotavljanje učinkov TG pri človeku praktično nemogoče, predvsem pri vraščanju v oba tunela, zato sledenje poteka neinvazivno z uporabo magnetne resonance (MR). Namen. Prvi namen raziskave je bil ugotoviti uporabnost novejših kvantitativnih MR metod, slikanja z difuzijsko obtežitvijo (Diffusion weighted imaging, DWI) in dinamičnega kontrastnega poudarjenega slikanja (Dynamic contrast enhanced imaging, DCEI), v kvantitativni oceni edema in prekrvljenosti v proksimalnem delu tibialnega tunela, ki je predstavljal interesno področje (Region of interest, ROI). Drugi namen raziskave je bil uporabiti obe kvantitativni MR metodi za oceno morebitnih učinkov intraoperativno lokalno apliciranega TG na edem in prekrvljenost v interesnem področju. Metode. Pri petdesetih bolnikih je bila opravljena artroskopska rekonstrukcija ACL. Testna skupina 25 bolnikov je intraoperativno lokalno prejela TG, medtem ko ga kontrolna skupina preostalih 25 bolnikov ni prejela. Pri vsakem bolniku smo opravili MR preiskavo en, dva in pol ter šest mesecev po posegu. Z DWI in DCEI smo pregledovali proksimalni del tibialnega tunela. Pri vsaki DWI preiskavi smo izračunali vrednost navideznega difuzijskega koeficienta (Apparent diffusion coefficient, ADC) kot merila za mobilnost vodnih molekul. Pri ocenjevanju prekrvljenosti smo pri vsaki DCEI preiskavi izračunali dva parametra: a) gradient obarvanja (G) kot merilo za hitrost obarvanja s paramagnetnim kontrastnim sredstvom (KS), in b) faktor obarvanja (F) kot merilo za jakost obarvanja. Rezultati. Povprečne vrednosti ADC kot tudi G in F so v obdobju sledenja v obeh skupinah med posameznimi kontrolnimi preiskavami značilno upadale. Primerjava skupin kaže, da je bila povprečna vrednost ADC v skupini, ki je prejela TG, en mesec po posegu 1,41 (10-3mm2/s) in značilno nižja kot v kontrolni (1,50 (10-3mm2/s)) skupini (p=0,033). Pri drugi in tretji kontroli razliki v povprečnih vrednostih ADC med skupinama nista bili značilni. Povprečna vrednost G je bila v testni skupini po enem (2,07 %/s) ter dveh in pol (1,64 %/s) mesecih značilno višja kot v kontrolni skupini (1,41 %/s po enem ter 1,15 %/s po dveh in pol mesecih, p=0,019 in p=0,008), pri tretji kontroli pa razlika ni bila značilna. Razlike v izračunanih povprečnih vrednostih F med skupinama pri nobeni kontrolni preiskavi niso bile značilne. Zaključek. Značilno nižja vrednost ADC v proksimalnem tibialnem tunelu skupine, ki je prejela TG, en mesec po rekonstrukciji, kaže na zmanjšanje mobilnosti vodnih molekul v tem področju v primerjavi s kontrolno skupino, kar pripisujemo gostejši celični organizaciji. Značilno višja vrednost G v skupini, ki je prejela TG, en ter dva in pol meseca po posegu, kaže na večjo gostoto krvnih žil v pregledanem področju v primerjavi s kontrolno skupino. Oboje dokazuje zgodnja učinka delovanja rastnih RF in drugih bioaktivnih proteinov v TG kot povečanje števila celic in večjo prekrvljenost v tibialnem tunelu, kar je v skladu s histološkimi opisi učinka RF na živalskih modelih. Kolikor vemo, gre za prvo uporabo DWI ter DCEI MR preiskave v področju ACL. Glede na rezultate naše raziskave ju zato predlagamo kot dodatni kvantitativni metodi ocenjevanja prihodnjih, hitro se razvijajočih modifikacij rekonstrukcije ACL.Background. Anterior cruciate ligament (ACL) rupture is one of the most common knee injuries. After reconstruction, slow processes of graft healing and ligamentisation require long rehabilitation period. Many modifications of the reconstruction technique have evolved over the time, among them in last decade the local application of platelet rich plasma gel (PRPG) as the carrier of various growth factors (GF). For ethical and technical reasons, histologic evaluation of ACL graft incorporation as well as of the effects of modifications of ACL reconstruction in humans is impossible. Therefore, their assessment has been performed mostly with magnetic resonance imaging (MRI). Purpose. The first purpose of the study was to assess the feasibility of two new quantitative MRI methods, diffusion weighted imaging (DWI) and dynamic contrast-enhanced imaging (DCEI), in the quantitative assessment of the oedema and vascularity in the proximal tibial tunnel. The second purpose was to assess the effect of locally applied PRPG during ACL reconstruction using two quantitative MRI sequences, DWI and DCEI, for the quantitative measurement of the tibial tunnel oedema and vascularity. Methods. In fifty patients, ACL reconstructions were performed by standard arthroscopic procedure. They were divided in two groups. The patients in the PRPG group locally received an application of PRPG into the tibial and femoral bone tunnels and into the graft itself, whereas patients in the control group did not receive any PRPG. For each patient, MRI examinations were performed one, two and a half and six months after the procedure. The proximal tibial tunnel was examined by DWI and DCEI, which were utilized to calculate apparent diffusion coefficient (ADC) values, which provide information on molecular motion of water, and the contrast enhancement gradient (G) and enhancement factor (F) values, which describe the enhancement rate and static enhancement after intravenously (i.v.) administered paramagnetic contrast medium (CM). Results. Calculated values of ADC, G and F in each group decreased significantly between the control examinations. In comparing the two groups, we find that at one month average ADC in the PRPG (1,41 (10-3mm2/s)) group was significantly lower than in the control (1,50 (10-3mm2/s)) group (p=0.033). At the second and third postoperative controls, the differences in the ADC values were not significant. At one month, average G was significantly higher in the PRPG (2,07 %/s) group than in the control (1,41 %/s) group (p=0.019). Also, at two and a half months, G was also significantly higher in the PRPG (1,64 %/s) group than in the control (1,15 %/s) group (p=0.008). At six months, there was no significant difference in the G between the groups. There were no significant differences in average F between the groups at any control examination. Conclusion. DWI and DCEI MRI proved to be feasible in noninvasive quantitative assessment of the oedema and vascularity in the healing process of ACL graft. In the proximal tibial tunnel, the effect of PRPG, measured with these two quantitative MRI methods, is mostly pronounced at early stages of the healing process. The significant decrease of ADC demonstrates diminished water mobility, presumably due do larger cellularity, in the first postoperative month. The significant increase of the G at one and two and a half months after reconstruction indicates higher vascular density as effect of the locally applied PRPG. Both results are in accordance with early histologic findings of enhanced fibrosis and angiogenesis as effects of intraoperatively administered GF in animal models. To our knowledge, this is the first time DWI and DCEI have been demonstrated in the area of ACL. We propose them as additional quantitative MRI modalities in the assessment of new, rapidly evolving modifications of ACL reconstruction technique

Quantitative evaluation of growth plates around the knees of adolescent soccer players by diffusion-weighted magnetic resonance imaging

Purpose. To quantitatively evaluate growth plates around the knees in adolescent soccer players utilizing the diffusion-weighted MR imaging (DWI). Methods. The knees and adjacent growth plates of eleven 14-year-old male soccer players were evaluated by MRI before (end of season´s summer break) and after two months of intense soccer training. MRI evaluation was conducted in coronal plane by PD-FSE and DWI. All images were screened for any major pathological changes. Later, central growth plate surface area (CGPSA) was measured and the apparent diffusion coefficient (ADC) values were calculated in two most central coronal slices divided into four regions: distal femur medial (DFM), distal femur lateral (DFL), proximal tibia medial (PTM), and proximal tibia lateral (PTL). Results. No gross pathology was diagnosed on MRI. CGPSA was not significantly reduced: DFM 278 versus 272, DFL 265 versus 261, PTM 193 versus 192, and PTL 214 versus 210. ADC decrease was statistically significant only for PTM: DFM 1.27 versus 1.22, DFL 1.37 versus 1.34, PTM 1.13 versus 1.03 (p=0.003), and PTL 1.28 versus 1.22. Conclusions. DWI measurements indicate increased cellularity in growth plates around knees in footballers most prominent in PTM after intense training. No detectable differences on a standard PD-FSE sequence were observed

Artroskopska anatomija in patoanatomija raztrganine sprednje križne vezi

Purpose: To arthroscopically evaluate the size variability of the Anterior cruciate ligament (ACL) insertion sites and to determine whether there are variations in rupture patterns of the two ACL bundles. Material and Methods: Ninetyfour patients undergoing ACL reconstruction between June 2008 and June 2009 were included in our study. The average age of the patients was 26.7 +/- 8.3 years (range, 1648 years). Only patients with an ACL rupture less than 120 days old were included as unpublished data revealed difficulty in distinguishing between AM and PL bundles in older ACL ruptures.Results: The femoral ACL insertion site length ranged from 11 to 20 mm (15.9 +/- 2.2). On the tibial side, the length of the tibial ACL insertion site ranged from 9 to 20 mm (16.0 +/- 2.1). On the femoral side, the width of the ACL insertion site ranged from 6 to 11 mm (8.3 +/- 1.2). On the tibial side, the width of the entire ACL insertion site ranged from 6 to 12 mm (8.7 +/- 1.1). The most frequent injury pattern was found to be the proximal rupture of both bundlesseen in 74 patients (78.7%). Conclusion: Both hypotheses were confirmed, and this may be clinically relevant in anatomic ACL reconstruction.Cilji: Artroskopsko smo želeli določiti variacijo velikosti narastišča sprednje križne vezi (SKV) ter ugotoviti, ali ima raztrganina sprednje križne vezi različne vzorce glede na dejstvo, da je sestavljena iz dveh snopov. Material in metode: V raziskavo je bilo vključenih 94 operiranih bolnikov s pretrgano sprednjo križno vezjo v obdobju od junija 2008 do junija 2009. Povprečna starost bolnikov je bila 26.7 +/- 8.3 (od 16 do 48 let). Vključitvena kriterija sta bila dva: pretrganje sprednje križne vezi in čas med poškodbo in operacijo , krajši od 120 dni. Ta kriterij je bil določen, ker se je pri prejšnji neobjavljeni raziskavi pokazalo, da je 120 dni po poškodbi težko ločiti oba snopa. Rezultati: Ugotovili smo, da je dolžina narastišča sprednje križne vezi na femur od 11 do 20 mm (15.9 +/- 2.2). Na tibiji je dolžina od 9 do 20 mm (16.0 +/- 2.1). Širina narastišča sprednje križne vezi na femur je od 6 do 11 mm (8.3 +/- 1.2). Širina narastišča sprednje križne vezi na tibijo je med 6 in 12 mm (8.7 +/- 1.1). Najpogostejši vzorec poškodbe sprednje križne vezi je bila raztrganina obeh snopov proksimalno, in sicer kar pri 74 bolnikih (78.7 %). Zaključek: Obe hipotezi sta bili potrjeni, kar je morda klinično pomembno pri rekonstrukciji sprednje križne vezi

Quantitative Evaluation of Growth Plates around the Knees of Adolescent Soccer Players by Diffusion-Weighted Magnetic Resonance Imaging

Purpose. To quantitatively evaluate growth plates around the knees in adolescent soccer players utilizing the diffusion-weighted MR imaging (DWI). Methods. The knees and adjacent growth plates of eleven 14-year-old male soccer players were evaluated by MRI before (end of season’s summer break) and after two months of intense soccer training. MRI evaluation was conducted in coronal plane by PD-FSE and DWI. All images were screened for any major pathological changes. Later, central growth plate surface area (CGPSA) was measured and the apparent diffusion coefficient (ADC) values were calculated in two most central coronal slices divided into four regions: distal femur medial (DFM), distal femur lateral (DFL), proximal tibia medial (PTM), and proximal tibia lateral (PTL). Results. No gross pathology was diagnosed on MRI. CGPSA was not significantly reduced: DFM 278 versus 272, DFL 265 versus 261, PTM 193 versus 192, and PTL 214 versus 210. ADC decrease was statistically significant only for PTM: DFM 1.27 versus 1.22, DFL 1.37 versus 1.34, PTM 1.13 versus 1.03 (p=0.003), and PTL 1.28 versus 1.22. Conclusions. DWI measurements indicate increased cellularity in growth plates around knees in footballers most prominent in PTM after intense training. No detectable differences on a standard PD-FSE sequence were observed

MRI Assessment of the Early Disc Degeneration Two Levels above Fused Lumbar Spine Segment: A Comparison after Unilateral and Bilateral Transforaminal Lumbar Interbody Fusion (TLIF) Procedure

Background: Adjacent segment degeneration (ASD) has become a great concern as a late complication in patients following fusion spine surgery with a potential need for revision surgery. Segments above the fused spine have higher mobility and they are especially prone to accelerated disc degeneration. The purpose of our study is to investigate early disc degenerative changes two levels above a surgically fused lumbar spine segment and to compare MRI analyses after unilateral and bilateral TLIF procedures. Methods: A total of 117 patients were included in this cross-sectional retrospective single center study (after bilateral TLIF surgery: n = 91, and after unilateral TLIF: n = 26). In both groups, the average patient age was similar: 62.84 years (SD = 12.53) in the unilateral TLIF group and 60.67 years (SD = 11.89) in the bilateral TLIF group. On average, MRI was performed 2.5 years after surgery (SD = 2.09). The modified eight-level Pfirrmann grading system was used for the assessment of disc degeneration severity. Descriptive statistics and the Mann–Whitney test were used to show differences in the Pfirrmann grades regarding the after-surgery period and the patient age. The Wilcoxon signed-rank test results were used to display differences in the Pfirrmann grades before and after surgery. Results: The comparison of mean values, regardless of the type of surgery, shows that this mean value is on average higher in the first segment adjacent to the fused spine segment. The assessment of the intervertebral disc structure in BIL TLIF is higher in both the first and the second segment. Early disc degeneration progression is subtle yet detectable (UNI TLIF 9.28% vs. BIL TLIF 16.74%). The assessment of the intervertebral disc structure is on average lower in patients aged less than 50 years at time of surgery compared with patients aged more than 50 years in UNI TLIF, and higher in the BIL TLIF group, for both the first and the second segment. Conclusion: Patients who had undergone unilateral TLIF fusion surgery have a lower rate of early disc degenerative changes. Considering a significantly higher rate of progressive disc degenerative changes in the elderly with bilateral fusion surgery, extra caution is required in the selection of appropriate surgical technique

Subspecialisation in radiology in Europe, a survey of the accreditation council of imaging

Abstract Background To provide an overview of existing Subspecialty Exams and Diplomas in Radiology and their endorsement as well as to providing an insight into the status of subspecialisation in radiology in Europe. The European Training Curriculum for Subspecialisation in Radiology mentions thirteen fields of subspecialisation within radiology. The websites of the corresponding subspecialty societies were checked for Subspecialty Exams and Diplomas. In addition, we performed a survey among European radiologists regarding subspecialisation in radiology. Results Ten out of 13 European subspecialty societies offer a European subspecialty diploma. At least 7 out of the 10 European subspecialties societies in radiology offering a European subspecialty diploma obtained European Society of Radiology (ESR) endorsement. Two out of 10 obtained European Union of Medical Specialists—Council of European Specialist Medical Assessment endorsement. Survey among European radiologists who were ESR full members in March 2021 demonstrated that almost 20% of respondents indicated that they have no subspecialisation. Another 15% indicated that their area of subspecialisation is not recognised in their country of work. Eighty-four percent of respondents would like their area of subspecialisation in radiology to be officially recognised. According to the respondents, the major benefit of having their subspecialisation in radiology officially recognised is personal interest (45%). Conclusions There is a desire for more subspecialty recognition in radiology among European radiologists. Therefore, European subspecialty diplomas in radiology fulfil a need. Furthermore, there is room for further harmonisation and implementation on a European level regarding subspecialty training and recognition in radiology. Critical relevance statement As there is a desire for more subspecialty recognition in radiology among European radiologists, European subspecialty diplomas in radiology fulfil a need and there is still room for further harmonisation and implementation on a European level regarding subspecialty training in radiology. Key points • Radiology has 13 subspecialties as per the European Training Curriculum for Subspecialisation. • Currently, 15 subspecialty diplomas are offered by European subspecialty societies in radiology • Members of the European Society of Radiology seek greater recognition of radiology subspecialties. Graphical Abstrac