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ABSTRACT |
Wednesday, May 3, 1:30 PM-3:30 PM
Abstracts 164-173
Moderators: Ken L. Schreibman, MD, PhD and Andy Haims, MD
1:30 PM
Keynote Address: Achilles: The Demi-God
Ken L. Schreibman, MD, PhD, University of Wisconsin, Madison, WI
1:50 PM
164. Comparison of Magnetic Resonance Imaging Findings in Patients with Peroneal Brevis Tendinopathy or Tenosynovitis and in Patients with Asymptomatic Peroneal Brevis Tendons
Kijowski R.; De Smet A.*; Radiology, University of Wisconsin Hospital, Madison, WI.
Address correspondence to A. De Smet (aa.desmet{at}hosp.wisc.edu)
Objective: Few previous studies have reported the magnetic resonance imaging (MRI) findings in patients who have an intact and normally located peroneal brevis tendon (PBT) but who have a clinically diagnosed PBT disorder (tendinopathy or tenosynovitis). We studied the MRI findings in this patient population and compared these findings to those of a control group of patients with no clinical evidence of a PBT disorder.
Materials and Methods: The study group consisted of 20 patients with a clinically diagnosed PBT disorder who had an intact and normally located PBT on MRI. The control group consisted of 30 patients of similar age with no clinical evidence of a PBT disorder. The axial proton density-weighted (PD) and T2-weighted (T2) spin-echo MRI images of all 50 patients were retrospectively reviewed to determine the presence of PBT thickening and 5 additional MRI findings. These MRI findings included 1) primarily intermediate (PI) or uniform intermediate (UI) signal within the PBT on one or more PD images, 2) PI or UI signal within the PBT on 3 consecutive PD images, 3) intermediate T2 signal within the PBT, 4) circumferential fluid > 3 mm within the PBT sheath, and 5) either PI or UI signal within the PBT on 3 consecutive PD images or circumferential fluid > 3 mm within the PBT sheath. Sensitivity and specificity and positive and negative odds ratios of these MRI findings for determining the presence or absence of a PBT disorder were calculated.
Results: No patient had thickening of the PBT. The sensitivity of MRI findings 1, 2, 3, 4, and 5 for determining the presence of a PBT disorder were 90%, 90%, 55%, 20%, and 100%, respectively. The specificity of MRI findings 1, 2, 3, 4, and 5 for determining the absence of a PBT disorder were 70%, 80%, 93%, 100%, and 80%, respectively. The positive odds ratios of MRI findings 1, 2, 3, 4 and 5 for determining the presence of a PBT disorder were 3.0, 4.5, 8.2, non-applicable (N/A), and 5.0, respectively. The negative odds ratios of MRI findings 1, 2, 3, 4, and 5 for determining the absence of a PBT disorder were 0.14, 0.13, 0.49, 0.80, and N/A respectively.
Conclusion: The presence of intermediate T2 signal within the PBT and circumferential tenosynovial fluid > 3 mm were the most specific but least sensitive indicators of a PBT disorder. The presence of either PI or UI signal within the PBT on 3 consecutive PD images or circumferential tenosynovial fluid > 3 mm was a highly sensitive (100%) and moderately specific (80%) indicator of a PBT disorder.
165. Anatomic Features of the Metatarsal Heads Simulating Erosive Disease: Cadaveric Study Using CT Scanning, Sectional Radiography, Dissection, and Histological Analysis
Torshizy H.1,2,3*; Hughes T.H.1; Trudell D.2; Resnick D.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 anatomic characteristics of the normal osseous contours of the metatarsal heads, emphasizing their differences from those of erosive articular disorders.
Materials and Methods: CT imaging of the metatarsal heads in six human cadaveric feet was performed, using three-dimensional models derived from the image data. Subsequently, five feet were sectioned in planes corresponding to those at imaging for anatomical correlation, while one foot was anatomically dissected for correlation. The normal anatomic osseous contours of the metatarsal heads were analyzed and described.
Results: Variations in the normal anatomical osseous contours, including those related to the medial and lateral condyles of the metatarsal heads were present in all specimens. Of note, the lateral condyle of the first metatarsal head was found to be more prominent than the medial condyle in all specimens. In addition, anatomical variations in the degree of curvature of the metatarsal heads were identified. Normal osseous concavities on the lateral and medial aspect of each metatarsal head corresponded to attachment of the collateral ligaments and the joint capsule. Variations in the degree of curvature of these contours were also noted. An intersesamoidal ridge, present on the plantar surface of the first metatarsal head, was identified in all specimens. However, variations in its deviation and prominence were present.
Conclusion: The normal anatomic contours of the metatarsal head are a potential major source for diagnostic error when viewing sectional CT and MR images in patients with suspected erosive arthritis. These normal variations, although common and varied, produce characteristic findings that can be differentiated from bone erosions.
166. High Resolution MRI Anatomy of Finger Flexor Pulleys Utilizing Four Different MRI Field Strengths
Taljanovic M.S.1*; Sheppard J.E.2; Gmitro A.F.1; Hunter T.B.1; Naples J.C.1; 1. Radiology, The University of Arizona HSC, Tucson, AZ; 2. Orthopaedic Surgery, The University of Arizona HSC, Tucson, AZ.
Address correspondence to M.S. Taljanovic (mihrat{at}radiology.arizona.edu)
Objective: To determine the potential benefits of high resolution isotropic MRI imaging for depiction of the fine anatomy of the flexor pulleys of the finger.
Materials and Methods: The MRI of an excised fifth cadaveric finger with slight flexion of the distal interphalangeal joint was acquired utilizing four different field strength MRI machines: 1.5T and 3.0T General Electric, and 4.7T Biospec and 9.4T DRX 400 Bruker MR machines. The imaging on the 4.7T and 9.4T machines was limited to the middle phalanx including the proximal and distal interphalangeal joints for the evaluation of the A3, A4, and A5 flexor pulleys. 1.5T imaging was performed with a 3-inch surface coil, and 3T imaging with a knee coil (due to non-availability of a smaller coil). The 4.7T and 9.4T imaging were performed with a 25 mm volume coil. 3DSPGR and T1W spin echo images were acquired in the axial and sagittal planes on the 1.5T and 3T machines with achieved resolution from 341-536 microns for various sequences. Additional gradient echo water excitation images were obtained on the 3T machine with achieved resolution of 341 microns. Isotropic 3D gradient echo imaging was performed on the 4.7T and 9.4T machines with 100 resolution. The images were evaluated by two observers by consensus as to the visualization of the A3, A4, and A5 flexor pulleys. After imaging, dissection of the finger was performed by an experienced hand surgeon to correlate the imaging findings with the surgical anatomy of the A3, A4, and A5 flexor pulleys.
Results: On the 1.5T study the A4 pulley was relatively well visualized on the sagittal and axial T1W images and the A3 and A5 pulleys were not visualized on any of sequences. On the 3T study the A4 pulley was best visualized on the sagittal WE images and T1W axial images, and the A3 and A5 pulleys were sub-optimally seen on the same images. Excellent visualization was made of the A4 pulley with both 4.7T and 9.4 T imaging, and the A3 and A5 pulleys were also relatively well visualized. Slightly better imaging contrast was noted with the 9.4T system. The imaging findings correlated with the surgical anatomy.
Conclusion: High resolution isotropic MRI of the flexor pulleys enables excellent visualization of the A4 finger pulley when compared with 1.5T and 3T MRI. It also improves visualization of the A3 and A5 flexor pulleys when compared with 3T imaging.
167. Sonographic Detection and Differentiation of Finger Tendon Rerupture from Adhesive Scarring after Primary Surgical Repair
Budovec J.J.*; Sudakoff G.S.; Dzwierzynski W.W.; Matloub H.S.; Sanger J.R.; Radiology and Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI.
Address correspondence to J.J. Budovec (jbudovec{at}earthlink.net)
Objective: Following the surgical repair of finger tendons, tendon re-rupture or adhesive scarring may limit finger range of motion. Differentiating complete or partial tendon rupture from adhesive scarring may be difficult due to equivocal clinical findings. Accurate imaging of finger tendons is critical to determine appropriate clinical management. Sonography of finger tendons is a modality that allows evaluation of tendon integrity in a dynamic real-time setting. The purpose of this study is to determine if sonography can be used to differentiate complete or partial tendon re-rupture from adhesive scarring in patients who have undergone primary tendon repair.
Materials and Methods: Retrospective review of the radiographic, clinical and surgical records of patients referred for finger sonography over a two-year period was performed. Twenty-six patients evaluated for finger tendon disruption preoperatively or following surgical repair were identified. The diagnosis of complete tendon tear was made when one or more of the following was identified: 1) presence of a definite gap between the proximal and distal tendon margins; 2) visualization of only the proximal tendon margin; 3) visualization of only the distal tendon margin. Diagnosis of a partial tear was made if there was focal tendon heterogeneity or enlargement without tendon gap. Adhesive scarring was diagnosed if the tendon appeared intact with synovial sheath thickening and restricted motion within the synovial sheath during dynamic evaluation.
Results: Thirty-two injured fingers were examined in 26 patients. Postoperative complications or re-injury to a surgically repaired digit accounted for 21 of the 26 cases. Sonography correctly identified tendon tear or adhesive scarring in 19 of 21 patients with two false-positive cases (sensitivity of 100%, specificity of 75%, positive-predictive value of 87%, negative-predictive value of 100%).
Conclusion: Sonography is an accurate and effective modality in differentiating partial or complete tendon tear from adhesive scarring in patients with prior surgical tendon repair.
168. MRI Appearance of Surgically Proven Thickened Accessory Anterior Inferior Tibiofibular Ligament (Bassett's Ligament)
Subhas N.1*; Vinson E.N.1; Cothran R.L.1; Nunley J.A.2; Helms C.A.1; Radiology, Duke University Medical Center, Durham, NC; 2. Orthopedic Surgery, Duke University Medical Center, Durham, NC.
Address correspondence to N. Subhas (subhas_n{at}yahoo.com)
Objective: A thickened accessory anterior inferior tibiofibular ligament (Bassett's ligament) of the ankle has been reported as a cause of anterolateral ankle impingement. It is located inferior to the anterior inferior tibiofibular ligament (AITFL) and parallels its course. Although Bassett's ligament has been described in surgical exploration and cadaver dissections, its imaging appearance has never been reported to our knowledge. The purpose of this study was to identify the MRI findings associated with surgically confirmed cases of a thickened Bassett's ligament.
Materials and Methods: 32 surgically confirmed cases of a thickened Bassett's ligament were found after review of 240 operative reports of ankle procedures performed at our institution over a 3 year period. 18 (10 males and 8 females, age range 18-61, mean age 30.1) of the 32 cases had a preoperative ankle MRI scan of the ankle at our institution. A separate cohort of 18 patients (5 males and 13 females, age range 15-60, mean age 31.3) with preoperative MRI scans and no report of a hypertrophied Bassett's ligament at surgery were selected as controls. Two musculoskeletal trained radiologists retrospectively reviewed the MRI scans and evaluated the lateral ankle joint for the presence of a ligamentous structure inferior to and separate from the AITFL. The integrity and appearance of AITFL, anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), talar dome cartilage, and anterolateral gutter were also noted.
Results: 16 (89%) of the 18 surgically proven cases of a thickened Bassett's ligament were found to have a thick band of tissue inferior to, separate from and paralleling the AITFL consistent with a hypertrophied Bassett's ligament on MRI. None of the controls had a similar finding. 9 (50%) of the 18 controls had a thin band of tissue in this location, consistent with a normal Bassett's ligament, while no ligament was visualized in the remaining 9 controls. Of the 18 cases with a thickened Bassett's ligament, 15 (83%) had associated abnormalities on MRI: 9 (50%) with an abnormal AITFL, 11 (61%) with an abnormal ATFL, 8 (44%) with an abnormal CFL, 6 (33%) with abnormal tissue in the anterolateral gutter, and 3 (17%) with cartilage abnormalities in the lateral talar dome.
Conclusion: Thickening of the Bassett's ligament can be identified by MRI with careful attention to the anterolateral ankle joint. It is usually associated with other lateral ankle abnormalities and can be a cause of anterolateral impingement.
169. MRI Findings in the Painful Accessory Os Naviculare
Sofis G.T.*; Helms C.A.; Radiology, Duke University Medical Center, Durham, NC.
Address correspondence to G.T. Sofis (georgesofis{at}hotmail.com)
Objective: There are very few papers in the radiology literature describing the MRI findings associated with a painful accessory os naviculare. Our objective is to correlate MRI findings in a large series of patients who have undergone surgery for a painful accessory os naviculare and to determine if there are findings that may help in preoperative planning. The second objective is to re-evaluate the incidence of the three types of accessory navicular in the normal population.
Materials and Methods: MRI findings were retrospectively correlated with operative reports in 14 patients who have undergone surgery for painful os naviculare. The postoperative findings were then compared to the MRI reports for assessment of the type of Os (I, II, or III) and associated bony, ligamentous, and tendinous injury. In addition we surveyed the last random 100 foot and ankle MRIs done at the Duke University Medical Center to reevaluate the incidence of os naviculare in the normal population. The MRI findings in the asymptomatic patients were used as a comparison for the symptomatic patients.
Results: Symptomatic (postoperative) patients: Bone marrow edema pattern was seen in both the accessory os and adjacent navicular in all 14 pts. Sclerosis of the os was seen in 1/14 patients. Fluid signal in the synchondrosis correlated with an operative description of a loose synchondrosis in 2/2 patients, but was seen on MRI in 4/14 of the symptomatic patients. Asymptomatic patients: Incidence of Type I - 6%, Type II - 7% and Type III - 10%. There was fluid in the synchondrosis in 2/7 and edema in 2/7 of the asymptomatic Type II patients.
Conclusion: We found the incidence of Type I, II, and III accessory os naviculare to be 6, 7 and 10 percent respectively. Our results support that the Type II os is the most likely to present with pain. Bone marrow edema is seen in 100% of symptomatic patients. Fluid in the synchondrosis suggests an unstable synchondrosis, but is not always seen in patients with severe symptoms and was seen in a few cases in the normal population.
170. Ultrasound of Wrist Ganglion Cysts: Variable and Non-cystic Appearances
Wang G.T.*; Feng F.Y.; Jacobson J.A.; Girish G.; Caoili E.; Ebrahim F.; Radiology, University of Michigan, Ann Arbor, MI.
Address correspondence to G.T. Wang (geowang{at}med.umich.edu)
Objective: In our clinical practice, we have noted wrist ganglion cysts that have not fulfilled the criteria for simple cysts. This study evaluates the ultrasound features of wrist ganglia.
Materials and Methods: Medical records from 1993 - 2003 were searched using ICD-9 code and key words "ganglion" and "ultrasound," and ultrasound log books from 2000 - 2004 were reviewed, which identified 20 wrist ganglion cysts in 16 patients proven at surgery or aspiration. Retrospective review of ultrasound images was carried out by two musculoskeletal radiologists. Images were evaluated for cyst location, volume, largest dimension, joint or tendon extension, echogenicity, septations, internal echogenicity, posterior acoustic enhancement, well-defined margins, lobularity, and vascularity.
Results: Of the 20 wrist ganglia, 15 were volar (10 between flexor carpi radialis and radial artery) and 5 were dorsal (2 over scapholunate ligament). The mean volume was 2,081 mm3 (range 90 - 15,000) and the mean largest dimension (MLD) was 17.3 mm (range 7 - 30). Seven volar ganglia demonstrated joint communication. Ten ganglia were anechoic, 7 hypoechoic, and 3 had anechoic and hypoechoic areas. Eight had septations, 8 had internal echogenic areas, 15 had posterior acoustic enhancement, 13 had well-defined margins, 12 were lobular (range 2 - 10 lobules), and none were vascular. Cysts with posterior acoustic enhancement (mean volume 2,707 mm3, MLD 20.4 mm) were significantly larger than those without (mean volume 198 mm3, MLD 8 mm) (p < 0.0001 and p = 0.018 for mean volume and MLD, respectively). Cysts that were anechoic were also significantly larger (volumes: 2,948 mm3 versus 468 mm3, MLD: 21 versus 9 mm) than those hypoechoic (p = 0.04 and 0.0002).
Conclusion: Small wrist ganglion cysts (< 10 mm in size) commonly are hypoechoic without posterior acoustic enhancement and do not fulfill the criteria for simple cyst.
171. Significance of Persistent Median Nerve Artery in Patients with a Bifid Median Nerve
Johnston C.*; Major N.; Helms C.; Radiology, Duke University Medical Center, Durham, NC.
Address correspondence to C. Johnston (ciaranjohnston{at}yahoo.co.uk)
Objective: Anatomic variations at the wrist are not uncommon, with reports of persistent median nerve arteries (PMNA) occurring in 1 to 16% patients and bifid median nerve in 3.3% patients in surgical series. Although a PMNA has been described as an anatomic variation in ultrasound and angiographic studies, to our knowledge, no report of MRI findings of a bifid median nerve and its association with a PMNA and symptoms of carpal tunnel syndrome has been described. The objective was therefore to determine the incidence of bifid median nerve with a PMNA on wrist MR examinations and observe their effect on the presence of symptoms.
Materials and Methods: Clinical notes and MR wrist examinations from 200 consecutive patients were retrospectively reviewed for the presence of a persistent median artery and bifid median nerve. MR imaging at 1.5T included coronal and axial T1 weighted (TR/TE 500/20 ms), and FSE T2w studies (TR/TE 2000/120ms). Studies were read by consensus by 2 MSK radiologists blinded to symptoms. Record was made of the presence of a bifid median nerve, the number and size of PMNA, and associated symptoms of carpal tunnel syndrome.
Results: A bifid median nerve was encountered in 36 patients (18%). Of these, 24 (67%) had a PMNA, with an average size of 1.4 mm (range 0.5 to 2.9 mm). 28 patients (14%) had a PMNA without a bifid median nerve, with an average size of 0.7 mm (range 0.4 to 1.1 mm). A larger persistent median artery (> 1.0 mm) was associated with a bifid median nerve (18/24 (75%) cases vs. 6/28 (21%) cases with arteries < 1 mm), as was the presence of multiple persistent median arteries (8/10 (80%) patients had bifid median nerves). Patients with symptoms of carpal tunnel syndrome were more likely to have persistent median nerve arteries (22/48 (42%) patients versus 30/152 (20%) patients referred for MR wrist for other reasons), and these arteries tended to be larger (1.8 mm in the symptomatic group versus 0.7 mm in the asymptomatic group). 2 patients had aneurysms of the PMNA with associated carpal tunnel syndrome
Conclusion: Bifid median nerves are a common finding at MR wrist, seen in 18% patients in this series. They are often associated with persistent median nerve arteries, especially when the arteries are large or multiple. Symptoms of carpal tunnel syndrome in these patients are common and awareness of this anatomical variation is important prior to surgery.
172. Ultrasound-Guided Intratendinous Injection of Hyperosmolar Dextrose in the Treatment of Chronic Tendinosis of the Infrapatellar and Achilles Tendons
Maxwell N.J.1*; Ryan M.2; Taunton J.E.2; Wong A.1; 1. Department of Radiology, St Paul's Hospital, Vancouver, BC, Canada; 2. Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.
Address correspondence to N.J. Maxwell (Normax{at}eircom.net)
Objective: Chronic tendinosis of the infrapatellar and achilles tendons are very common overuse injuries not just in athletes but in the general population. There is no truly effectivetreatment option for these patients. We report on our experience of using intratendinous injection of hyperosmolar dextrose in the treatment of these conditions.
Materials and Methods: 30 patients (22 men, 8 women, mean age 50.0 yrs, range (18-83)) with chronic tendinosis of either the achilles tendon (23 tendons) or the infrapatellar tendon (9 tendons) underwent ultrasound guided intratendinous injection of hyperosmolar dextrose (25%). Injections were repeated approximately every 6 weeks until symptoms resolved or no improvement was evident. Clinical assessment was performed at baseline and prior to each injection using a Visual Analogue Scale, (0, no pain; 100, severe pain), for tendon pain at rest (VAS1), tendon pain during normal daily activity(VAS2) and tendon pain during or after sporting or other physical activity (VAS3). Using a Philips HDL 5000, and a 15-7MHz linear high resolution probe, sonography was performed pre and post injection. Tendon thickness, echogenicity, neovascularity and the post injection spread of the dextrose solution within the tendon was recorded.
Results: 24 of the 30 patients were very satisfied with the outcome of their treatment. 3 patients did not respond to the treatment and opted for surgery. 3 further patients had incomplete treatment and did not keep their follow up appointments. A mean of 4.0 injection sessions per tendon (range 2-11) was performed. The VAS scores for the 24 patients who completed treatment showed statistically significant reduction in tendon pain. For the achilles tendon % mean change for VAS1, 87.1%; VAS2, 84.7%; VAS3, 82.2%. For the infrapatellar tendon VAS1, 66.7%; VAS2, 74.8%; VAS3 72.0%. It was noted that the patients who did not respond to the injection therapy had cortical irregularity and calcification at the tendon insertion. All tendons were thickened and demonstrated changes consistent with chronic tendinosis prior to treatment. There was minimal sonographic change post treatment.
Conclusion: Results indicate that intratendinous injections of hyperosmolar dextrose is a very effective treatment for chronic tendinosis of the achilles and infrapatellar tendons, with significant reduction in tendon pain allowing patients to return to their pre-injury level of activity.
173. MR Imaging Patterns of Cartilage and Osseous Degenerative Change as a Function of Patellar Facet Anatomy: Correlation of Standard Clinical MR Imaging Sequences, T2 Mapping, and Histological Correlation in 19 Cadaveric Specimen
Chong-Han C.H.1,2*; Dwek J.3; Znamirowski R.,; Bydder G.2; Frank L.1,2; Resnick D.1; Chung C.B.1,2; 1. Radiology, Veterans Affairs San Diego Health-care System, La Jolla, CA; 2. Radiology, UCSD Medical Center, San Diego, CA; 3. Radiology, Children's Hospital and Health Care Center, San Diego, CA.
Address correspondence to C.H. Chong-Han (c_chonghan{at}yahoo.com)
Objective: To identify the pattern and extent of degenerative cartilage and osseous change at the odd, medial, and lateral facets of the patella with MR imaging, T2 mapping, and histological correlation
Materials and Methods: T1 and proton density-weighted
fat-suppressed axial images were obtained using a 1.5 Tesla magnet on 19
cadaveric patellae. Odd, medial, and lateral facets of the patella were
analyzed for cartilage and osseous changes. For each facet, we determined the
presence of cartilage defect, cartilage width at the facet midpoint, maximum
cartilage thickness, and transverse facet dimension. Based on our measurements
and MR appearance of the articular cartilage, we categorized each facet as
heterogeneous cartilage signal, articular surface irregularity, cartilage
defects less than 
the maximum width, cartilage defects greater than
the maximum width, or exposed bone. Subchondral bone changes and
osteophytosis were also recorded for each facet. T2 mapping and histological
correlation were performed.
Results: Odd facets were noted in 15 of 19 (79%) patellae. Thirty odd, medial, and lateral facets were analyzed from two axial images through each patella containing an odd facet. Normal cartilage was observed in 0 odd, 7 medial, and 8 lateral facets, while heterogeneous cartilage signal without focal defect was seen in 6 odd, 9 medial, and 5 lateral facets. We also noted surface irregularity of cartilage in 3 odd, 5 medial, and 8 lateral facets. Cartilage defects less than one-half the maximum cartilage thickness was identified in 7 odd, 2 medial, and 3 lateral facets. Similarly, greater than one-half cartilage thickness defects was present in 5 odd, 3 medial, and 2 lateral facets. We observed exposed bone in 5 odd facets, while both medial and lateral facets contained no exposed bone. Subchondral bone changes were similar across all three facets. Findings correlated with qualitative and quantitative T2 data as well as histology.
Conclusion: Our results suggest that degenerative changes of the cartilage occur most profoundly at the odd facet. The medial and lateral facets have similar extent of degenerative changes. Examining the pattern of degenerative change as related to facet anatomy may be useful in understanding the pathogenesis of osteoarthritis.
* Will present paper
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