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ABSTRACT |
Tuesday, May 2, 1:30 PM-3:30 PM
Abstracts 154-163
Moderators: Donna G. Blankenbaker, MD and Johnny U.V. Monu, MD
1:30 PM
Keynote Address: Update on Imaging of Sacroiliitis
Donna G. Blankenbaker, MD, University of Wisconsin, Madison, WI
1:50 PM
154. Inflammation of Hoffa's Fat Pad in the Setting of HIV: MR Imaging Findings in 5 Patients
Torshizy H.1,2,3*; Pathria M.1,2; Chung C.1,2; 1. Radiology, University of California, San Diego, San Diego, CA; 2. Radiology, Veterans Affairs (VA) San Diego Healthcare System, San Diego, CA; 3. School of Medicine, University of California, Irvine, Irvine, CA.
Address correspondence to H. Torshizy (htorshiz{at}hotmail.com)
Objective: To describe MR imaging findings of inflammation of Hoffa's fat pad as a cause of nonspecific knee pain in the HIV-infected patient population.
Materials and Methods: A retrospective review of 400 consecutive MR imaging studies of the knee performed at two institutions over a 6 month period was performed. Inclusion criteria for studies included positive HIV status in conjunction with diffuse, global abnormal high signal intensity throughout Hoffa's fat pad on fluid sensitive sequences. Medical histories were reviewed with particular attention to: HIV status (including time of diagnosis if available), antiretroviral medication history, history of internal derangement, history of knee arthroscopy or other surgical intervention, history of chronic synovial abnormalities, and history of other musculoskeletal diseases. MR imaging studies were reviewed by two musculoskeletal radiologists. Exclusion criteria included: 1) post-arthroscopic or post-surgical changes, 2) internal derangement, 3) and/or abnormalities consistent with an active synovial inflammatory process.
Results: A total of 6 patients with a history of HIV were identified, 5 of which met inclusion criteria. Seven studies, from these 5 patients presented with non-specific knee pain, and were identified to have diffuse abnormal high signal intensity throughout Hoffa's fat pad on fluid sensitive sequences. Two patients presented with bilateral findings. Images of all 7 knees demonstrated small joint effusion. Avascular necrosis of the lateral femoral condyle along its articular surface was present in one image. All patients were taking anti-retroviral medication for an extended duration of time prior to imaging. Patients selected were diagnosed with HIV in a time period spanning from 1993 to 1999.
Conclusion: While the MR imaging findings of diffuse inflammation of Hoffa's fat pad are nonspecific and in many cases its etiology unclear, an association with HIV positive status may exist.
155. Comparison of CT and MRI in Patients With Acute Tibial Plateau Fracture: Can CT Findings Predict Ligament Tear or Meniscal Injury?
Mui L.*; Engelsohn E.; Umans H.; Radiology, Jacobi Medical Center, Bronx, NY.
Address correspondence to L. Mui (leowmui{at}yahoo.com)
Objective: To compare CT and MRI data in patients with acute tibial plateau fracture to determine 1) CT criteria which might predict ligamentous injury and 2) assess if CT findings correlate with meniscal injury as identified by MRI.
Materials and Methods: We reviewed all imaging and surgical data for patients presenting to our institution from 12/01-8/05 with acute tibial plateau fracture in whom CT and MRI were obtained pre-operatively (n = 41). MRI and CT images were separately analyzed for: Schatzker classification, intercondylar eminence fracture or fibular avulsion, maximal articular gapping and depression. CT images were reviewed, blinded to MRI data, to determine if ligament tear could be detected. Insertion site avulsions were deemed indicative of intact corresponding ligaments. Smooth visible contours on reformatted images without silhouetting suggested intact ligaments. Injury mechanism based on site of articular impaction was used to determine integrity of collateral ligaments. Sensitivity, specificity and PPV of these findings were assessed using MRI as gold standard. Meniscal injury as determined by MRI was correlated independently with maximal articular gapping, depression, ligamentous injury with and without intercondylar eminence fracture or fibular avulsion, all as judged by CT.
Results: Meniscal injury was present in 58.5%. There were 14 ligament tears in 11 patients. CT demonstrated ligament tear with: 78.5% sensitivity, 98.6% specificity and PPV 84.6%. Average articular gap in those with and without meniscal injury was 1.2 cm and 0.5 cm respectively (p = 0.004). Average articular depression in those with and without meniscal injury was 0.9 cm and 0.4 cm, respectively (p = 0.003). ROC analysis demonstrated no clear threshold for gap or depression that yielded a combination of high sensitivity and specificity. Chi Square analysis of CT findings of ligament tear or avulsion as correlated with presence of meniscal injury by MRI did not reach statistical significance.
Conclusion: MRI has been reported to accurately delineate plateau fracture classification, demonstrate articular depression and gapping, and elucidate associated soft tissue injury, yet CT remains a mainstay of pre-operative imaging in many institutions. Although we demonstrate good sensitivity and excellent specificity in CT prediction of ligamentous injury, CT criteria do not correlate well for prediction of significant meniscal injury. As such, CT does not preclude the necessity for pre-operative MRI.
156. Does Exercise Provoke Joint Effusions? A Systematic Ultrasound Evaluation
Boriskin H.S.*; Cunningham P.M.; Schweitzer M.E.; Radiology, NYU School of Medicine/ Hospital for Joint Diseases, New York, NY.
Address correspondence to H.S. Boriskin (hboriskin{at}gmail.com)
Objective: Anecdotally, exercise has been associated with joint effusions. We sought to systematically evaluate this question as well as compare if this response is dependent on baseline patient activity using ultrasound.
Materials and Methods: 22 volunteers were studied. Patients had a baseline ultrasound of their suprapatellar bursa performed by two observers with the area of their effusion at baseline calculated. The patients walked down 52 flights of stairs; meant to be a noncardiovascular activity, with an immediate repeat ultrasound performed by the same two observers. Questionnaires were utilized to determine baseline physical activity of their lower extremities and patients were categorized as either exercising regularly or not.
Results: The range in area at baseline was 0.01-1.67 cm3 (mean .47). Patients who exercise regularly had a greater baseline value (0.55 cm3 vs. 0.36 cm3). Following exercise the range was 0.03-3.78 cm3 (mean 0.84 cm3). The overall mean change in area was 0.37 cm3, which represented a 125% increased in area over baseline. 16 patients had an increase in fluid, 5 patients had a decrease in fluid, and 1 had no change. This did not vary with baseline physical activity. However, patients who exercise regularly had a mean increase in area of 0.40 cm3 (141%) vs. 0.33 cm3 (103%) for those who did not.
Conclusion: Baseline volume of fluid in the suprapatellar bursa is quite variable. The variability appears in part to be related to how active the individual is, with the base-line volume of fluid being greater in those individuals who regularly exercise their lower extremities. Noncardiovascular exercise appears to provoke effusions in individuals regardless of baseline activity, but causes a greater percent increase in change in those who exercise regularly.
157. Clinical Predictors of Diagnostic Yield of Spinal Percutaneous Core Biopsy in Suspected Discitis/Osteomyelitis
Shetty S.K.*; Bredella M.A.; Kassarjian A.; Department of Radiology, Division of Musculoskeletal Radiology, Massachusetts General Hospital, Boston, MA.
Address correspondence to S.K. Shetty (sshetty{at}partners.org)
Objective: To determine the effect of antibiotic therapy on diagnostic yield of CT-guided diagnostic percutaneous core biopsy (PCB) of the spine in cases of suspected spinal infection.
Materials and Methods: 63 consecutive CT-guided PCB procedures performed for suspected spinal infection were retrospectively reviewed. Each patient record was reviewed to identify clinical information available at the time of biopsy, including current antibiotics, previous antibiotics (duration and interval since antibiotic exposure), white blood cell count, erythrocyte sedimentation rate (ESR), history of fevers, and blood culture results. Technical details of each biopsy procedure, including the site of biopsy (disc, vertebral body, and/or paraspinal soft tissues) and the gauge of the biopsy sample, were also collected. Diagnostic yield was defined as successful identification of a causative organism on histology, stain, or culture of the core sample.
Results: Overall diagnostic yield of spinal PCB was 34.9% (22/63). Core biopsy samples were obtained in every case, with sample sizes ranging from 13 to 20 gauge. Causative organisms identified through PCB included bacterial organisms (18 cases), tuberculosis (1 case), mycobacterium avium complex (MAC, 2 cases), and candida albicans (1 case). No significant difference in diagnostic yield was seen between patients who were undergoing antibiotic treatment at the time of biopsy (8/27, 28.6%) and those who were not (14/36, 38.9%) (p = 0.445), even when excluding cases that were ultimately found to have fungal or mycobacterial infections (p = 0.38). Similarly, no difference in yield was seen when adding patients who had recently been exposed to antibiotic therapy (less than 3, 4, 7, or 30 days prior to biopsy). Clinical information available at the time of biopsy - including abnormal white blood cell count, elevated ESR, positive blood culture, or history of fever - was not helpful in predicting diagnostic yield (p = 0.39, p = 0.92, p = 0.20, and p = 0.86 respectively). The site of biopsy and size of the core specimen did not predict diagnostic yield.
Conclusion: Recent or ongoing antibiotic therapy did not alter the diagnostic yield of CT-guided PCB of the spine in patients with suspected discitis/osteomyelitis.
158. MR Imaging Findings of Calf Muscle Injuries
Koulouris G.1,2*; Jhamb A.1; Connell D.A.1; Ting A.1; 1. Radiology, Victoria House Medical Imaging, Melbourne, VIC, Australia; 2. Musculoskeletal Division, Thomas Jefferson University Hospital, Philadelphia, PA.
Address correspondence to G. Koulouris (drgeorgel{at}gmail.com)
Objective: To describe the imaging findings following acute injury to the calf musculature.
Materials and Methods: We retrospectively reviewed 56 MR examinations in patients who sustained injuries to the calf muscle from April 2001 - September 2004 (45 males, eleven females), with an average age of 31 and 47 years respectively (male range 20-53; female range 33-63). Attention was directed to the frequency of muscle involvement, the location of the injury within the musculotendinous unit and the extent of the injury.
Results: A total of 75 strains were observed (37 solitary, 19 dual). Of the 37 isolated strain, injury to the gastrocnemius was most common (54%; 20/37), namely, the musculotendinous junction of the medial head (65%; 13/20). Isolated strain to the soleus muscle occurred in 15/37 (41%), with two (5%) distal avulsions of the plantaris. Myofascial injury of the medial aspect of soleus was equally as common as musculotendinous strain on this side (40%; 6/15), with myofascial strain on the lateral side accounting for the remainder (20%; 3/15). Of the 19 dual injuries, a combination of gastrocnemius with soleus injury was the most frequent finding (58%; 11/19). Dual injuries within the soleus occurred twice, as observed for gastrocnemius. Other injuries involved a combination of the soleus-tibialis posterior (3) and the soleus-flexor hallucis (1). Of the 75 injuries, 45 (61%) had an identifiable hematoma, though in only 9/45 (20%) was discrete myofibril disruption present. Most injuries were acute (60/75; 80%) with the remainder subacute/chronic (15; 20%). Average muscle injury size was 2.5cm (range 0.3-8) in width and 5.5 cm (range 1.5-12) in length. When present, haematoma tracked between the intermuscular fascial planes 34/45 occasions (75%), being restricted to within the muscle less commonly (25%; 11/45). Fifteen patients had risk factors for calf strain (8 prior history, 7 past history of Achilles tendinopathy). Of those with a past clinical history of calf strain (8), scar tissue was identified in four. Two patients had anterior cruciate ligament strain, which was the primary indication for the imaging.
Conclusion: Our MR data concurs with sports medicine clinical findings that the medial head of gastrocnemius is the most commonly injured muscle of the calf. Further work with sonographic and clinical correlation, with particular attention to prognosis and time for return to competition will further highlight the importance of imaging, especially in the elite athletic population.
159. 3.0T MRI Evaluation of Articular Cartilage Injuries of the Knee
Major N.M.; Toomayan G.A.*; Cacchio P.; Radiology, Duke University Medical Center, Durham, NC.
Address correspondence to G.A. Toomayan (glen.toomayan{at}duke.edu)
Objective: To determine the diagnostic efficacy of 3.0T MRI in the evaluation of articular cartilage injuries of the knee by comparison with arthroscopy.
Materials and Methods: IRB approval was obtained. Eight patients (7 male, 1 female; 5 left knees, 3 right knees; mean age 25, range 13-53) who underwent 3.0T knee MRI for evaluation of ligamentous, meniscal, or articular cartilage injury and subsequent arthroscopy were included. The following sequences were independently evaluated for evidence of articular cartilage injury by two musculoskeletal radiologists blinded to patient identities and arthroscopic findings: sagittal fast spin echo (FSE) T2-weighted images (TR 4,000-4,400, TE 70-74, FoV 16 cm), coronal FSE T2-weighted images (TR 4,000-4,400, TE 70-74, FoV 16 cm), axial FSE T2-weighted images (TR 4,000-4,400, TE 70-74, FoV 16 cm), and sagittal three-dimensional double-echo steady state (3D-DESS) images (TR 15.5, TE 4.5, FoV 16 cm). Seven articular surfaces for each knee were graded by MRI and arthroscopy with the use of a 6-point modified Outerbridge classification. Grades 0 and 1 (cartilage intact or surface irregularity) were regarded as disease-negative and grades 2-5 (loss of cartilage) were regarded as disease-positive.
Results: Of 56 surfaces assessed at arthroscopy, 10 were disease-positive. The first radiologist identified 15 disease-positive surfaces by MRI (sens 88%, spec 83%, PPV 50%, NPV 98%, accuracy 84%). The second radiologist identified 13 disease-positive surfaces (sens 80%, spec 89%, PPV 62%, NPV 95%, accuracy 88%). Radiologists agreed on disease-positive or -negative status for 86% (48/56) of surfaces. Grading for the first radiologist matched arthroscopy for 64% of surfaces, was within one grade for 86% of surfaces, and was within two grades for 95% of surfaces. Grading for the second radiologist matched arthroscopy for 68% of surfaces, was within one grade for 84% of surfaces, and was within two grades for 93% of surfaces.
Conclusion: 3.0T MRI is as efficacious in diagnosing articular cartilage injuries in the knee as previously published studies utilizing 1.5T MRI. A diagnosis of normal articular cartilage by 3.0T MRI is an excellent indicator of normal articular cartilage at arthroscopy.
160. MRI of Psoriatic Arthropathy: Continued Observations in Fifty-Five Studies
Chan K.*; Monu J.U.*; Seo G.; Bang C.; Bakman M.; Anandarajah A.; Ritchlin C.; Radiology, University of Rochester School of Medicine and Dentistry, Rochester, NY.
Address correspondence to K. Chan (karen_chan{at}urmc.rochester.edu)
Objective: The role of MRI in the management of specific arthritides especially psoriatic arthropathy (PsA) has yet to be established. The relatively higher cost of MRI compared to plain radiography continues to limit use of MRI for assessing disease activity. The purpose of this study is to assess the occurrence of and extent of abnormalities seen on MRI in psoriatic arthropathy (PsA).
Materials and Methods: Fifty-five MRI studies from 16 male and 14 female patients aged between 34 and 61 years old who had radiographic erosive disease and clinically active PsA were reviewed for patterns of abnormalities. The most symptomatic joint including the knee, the wrist, and the ankle the fingers and the toes were scanned in each patient. All the patients had images in at least two or three orthogonal planes using T1W and T2W spin echo (SE) sequences. All the patients had post contrast studies utilizing fat suppressed T1W SE sequences. The images were evaluated forabnormal patterns in the bone, synovium and para-articular soft tissue. Signal pattern, contrast enhancement, size and number of locations of abnormalities were assessed. Weighted scores were assigned for a maximum score of 3 and a minimum of 0 in each parameter. The studies were reviewed by three experienced musculoskeletal radiologists.
Results: Joint effusion had a mean score of 2.37 in 1.44 locations (1.65). Proliferative bone changes had a score of 2.8 in 2.18 locations (1.32). Para-articular soft tissue scored 2.31 in 2.0 locations (1.15). Synovial score was 2.43 in 2.0 locations (1.17) and bone marrow abnormality scored 5.82 in 1.85 locations (3.15 or `3'). Although cysts were not specifically scored, evolving cysts were observed in 4 patients.
Conclusion: From the weighted scores it would appear that the bone marrow abnormality and synovial abnormality are signal events in PSA. These changes are not observable using any imaging modalities other than MRI. MRI should be used more frequently in the management of active PSA.
161. Value of Pulse-Inversion Harmonic Imaging of Inflammation Activity in Rheumatoid Arthritis
Schueller-Weidekamm C.*; Schueller G.; Krestan C.; Kainberger F.; Department of Radiology, Medical University of Vienna, Vienna, Austria.
Address correspondence to C. Schueller-Weidekamm (claudia.schueller-weidekamm{at}meduniwien.ac.at)
Objective: To evaluate the value of contrast enhanced pulse-inversion harmonic imaging (PI-HI) on both the synovial vascularization and the therapeutic effects on the inflammation of finger joints in rheumatoid arthritis (RA).
Materials and Methods: Two-hundred-eighty finger joints (MCP I-V, IP, PIP II-V) of 14 patients (10 females, 4 males) with RA were investigated with Power Doppler and PI-HI ultrasound after i.v. application of an ultrasound contrast media of the second generation. With Power Doppler, one finger joint per patient representing the strongest hypervascularization before steroid therapy was determined. Dynamic examination with PI-HI of the selected joint was carried out before and after 7 days of middle-high dosed steroid therapy. Vascularization was quantified by calculating the area underlying time-intensity curves [dB]. The changes of the signal intensities before and after therapy were correlated with clinical examinations (DAS-score).
Results: All patients showed a statistically significant reduction of PI-HI signals after steroid therapy (p < 0.05) The baseline and follow up median values of the area underlying time-intensity curves were 8.56 ± 1.28 and 7.65 ± 0.66, respectively. The median values of the DAS decreased significantly from 4.9 ± 0.86 to 3.6 ± 1.0 (p < 0.01) 7 days after the steroid therapy.
Conclusion: PI-HI enables the detection of synovial perfusion alterations after steroid therapy, and therefore may be an additional useful tool in the evaluation of active inflammation in RA and in the assessment of the therapeutic response.
162. The Risers Injury: Characteristic MR Findings in Parachute-Related Knee Dislocation and Multiligamentous Injury
Williams L.R.1; Bui-Mansfield L.T.2,3,4*; Kragh J.F.5; Lomis N.T.1; Bobbitt W.K.1; 1. Department of Radiology, Womack Army Medical Center, Fort Bragg, NC; 2. Department of Radiology, Brooke Army Medical Center, San Antonio, TX; 3. Department of Radiology, Wake Forest University, Winston-Salem, NC; 4. Department of Radiology, Uniformed Services University of Health Sciences, Bethesda, MD; 5. Department of Orthopedics, Brooke Army Medical Center, San Antonio, TX.
Address correspondence to L.T. Bui-Mansfield (liem_mansfield{at}hotmail.com)
Objective: The objective of this presentation is to report the MR findings associated with the parachute-related risers injury. The risers are the straps from the soldier's harness to the parachute cords. At the time of chute deployment, the risers can violently abduct the leg causing knee dislocation. This is the largest series of parachute risers injuries reported.
Materials and Methods: The clinical histories for all MR examinations of the knee performed on active duty soldiers at Fort Bragg, North Carolina for the past five years were reviewed. Risers entanglement injury during parachuting was the primary clinical history for 39 (0.6%) of the 5858 non-contrast knee MR examinations performed during this time. One musculoskeletal radiologist and one MR radiologist retrospectively reviewed all cases with any discrepancies resolved by consensus. Specific abnormalities identified and recorded in Excel spreadsheet format for the 39 risers entanglement cases included tears of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), fibular collateral ligament (FCL), medial patellofemoral ligament (MPFL), lateral patellofemoral ligament (LPFL), posterolateral corner structures, medial meniscus, and lateral meniscus. Other abnormalities recorded included the location of bone contusions or fractures and tears of less frequently injured structures such as the patellar and quadriceps tendons. The diagnoses of peroneal nerve and popliteal artery injury were evaluated for utilizing the MR images, more detailed clinical history from the Hospital Information System/Radiology Information System, and angiography results when performed.
Results: The patients had the following incidence of ligamentous tears by MR imaging: 92% ACL, 82% PCL, 82% MCL, and 44% FCL. Two distinct patterns of injury were present. Of the 32 patients having MCL tears, 25 also had tears of the MPFL and blowout of the medial capsule. The other 7 patients had posterolateral corner disruption. Peroneal nerve injury was present only in this subset. Popliteal artery injury, meniscal tears, and fractures with articular involvement were uncommon, each occurring in only 2 patients.
Conclusion: Risers injury is an abduction-traction injury of the knee, resulting in multiligamentous tears with a 5% association of vascular injury, meniscal tears, and fractures. Distinct medial and posterolateral injury patterns occur, and knowledge of the anticipated injuries for both patterns is essential.
163. Diagnostic Ultrasound as an Essential Screening Procedure in Detection of Non-Radiopaque Foreign Bodies in the Musculoskeletal System and Importance of Power Doppler
Nath A.K.*; Sethu A.U.; Radiology Department, Khoula Hospital, Muscat, Muscat, Oman.
Address correspondence to A.K. Nath (ashok{at}omantel.net.om)
Objective: To evaluate the use of ultrasonography in non-radiopaque foreign bodies in the musculoskeletal system and value of Power Doppler.
Materials and Methods: Sonography was performed in 50 patients presenting with definite history of foreign body injuries. All patients underwent low KV plain radiography of the affected area and sonography of the affected and contralateral normal area. The technique of scanning using Toshiba Power Vision 6000 S with 7.5-12 MHz phased linear array transducer along with power doppler is described. Surgery was done in all patients. Size and depth of the foreign bodies were noted both on sonography and surgery and results compared. Pitfalls, difficult situations, and possible solutions will be discussed.
Results: No foreign bodies were detected on plain x-ray. 46 patients showed evidence of foreign body on ultrasound examination. Sonographically foreign bodies were visualized as hyperechoic foci. Correct size and depth on sonography were found in 46 and 40 cases respectively. Additional findings were comet-tail artifact and acoustic shadow. 41 date thorns and 5 pieces of wood were found.
Conclusion: Ultrasonography had proved to be useful in detection, precise localization and pre-operative assessment of non-radiopaque foreign bodies in the musculoskeletal system. Power Doppler helped to outline area of inflammation with vessels.
* Will present paper
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