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Metatarsophalangeal joint capsule tears: an analysis by arthrography, a new classification system and surgical management.

Metatarsalgia is a common presenting symptom with an established list of differential diagnoses. The authors present a classification system and surgical treatment algorithm for chronic metatarsophalangeal pain due to metatarsophalangeal joint capsule tear. A series of 58 metatarsophalangeal joints with partial tear diagnosed by arthrogram and treated by surgical repair are reviewed. The authors propose a classification system based on preoperative arthrography and a surgical repair procedure for each type of three distinct patterns. A study was developed and funded to perform postoperative arthrograms on 15 patients who had undergone surgical repair using the procedures presented. The purpose of the study was to validate the utility of the arthrogram in the diagnosis and clarification of the nature of the capsular tear. The authors were also able to demonstrate that the arthrographic findings became normal postoperatively, and that surgical repair of a seemingly innocuous capsule tear relieves pain. Fifty-six patients in the series reported relief of their preoperative symptoms. Postoperative arthrograms in 15 patients demonstrated a normal pattern in 73%, 20% had decreased extravasation, and 7% were unchanged.

Adult↗

Magnetic resonance arthrography of the temporomandibular joint.

PURPOSE: This study evaluated the usefulness of magnetic resonance arthrography (MRAr) in imaging the pathologic temporomandibular joint (TMJ). PATIENTS AND METHODS: Thirteen TMJs of 11 patients with chronic TMJ pain and disability were examined with MRAr. T1-weighted and T2-weighted first spin-echo sequence with fat suppression images were obtained after the intra-articular injection of gadopentetate dimeglumine. RESULTS: The disc, the posterior attachment, and the presence of perforations and adhesions were evaluated in each image. All of these anatomic and pathologic structures were clearly detected. CONCLUSION: MRAr appears to be a promising imaging modality in detecting adhesions and perforations in the TMJ. The MRAr findings simplified the decision of whether a patient should undergo surgery.

Adult↗

[Indirect MR Arthrography of the wrist in the diagnosis of TFCC-Lesions].

PURPOSE: The objective of this prospective study was to assess the value of the indirect MR arthrography (MR-AR) of the wrist in the detection of lesions of the TFCC. MATERIAL AND METHODS: Indirect MR-AR was performed in 45 patients (23 f/22 m) with unclear ulnar wrist pain. After i. v. injection of 0.1 mmol/kg Gd-DTPA and after a motion-phase of the wrist (15 minutes) MRI was performed in a coronal plane. We used a STIR-, a fatsaturated (fs) T1-SE and a 3D-DESS sequence. The images were evaluated by two radiologists using a consensus score. The lesions were assigned to the system of Palmer and correlated with arthroscopy. RESULTS: Indirect MR-AR showed in 35 of 45 patients a lesion of the TFCC, but arthroscopy only revealed a defect in 32 cases. This means three false positive but no false negative assessments by MRI. Using this MRI protocol sensitivity and specificity in the detection of TFCC lesions were calculated as 100 % and 77 %. The accuracy was 93 %. Small degenerative changes of the fibres were most common (Palmer type II A). In trauma patients the ligaments usually showed tears near the insertion at the ulna (Palmer type I B). The sensitivity and specificity was 88 % and 95 % for evaluation of the scapho-lunate (SL) ligament, the accuracy was 93 %. Arthroscopy and MRI did not diagnose any rupture of the lunate-triquetral (LT) ligament. CONCLUSION: Indirect MR-AR is a non-invasive method with a high sensitivity in the evaluation of the TFCC and associated injuries. Therefore, it is an excellent screening procedure to assess the indication for therapeutic arthroscopy.

Adolescent↗

[MR-Arthrography with radial sequences for visualization of early hip pathology not visible on plain radiographs].

AIM: We wanted to improve MRI visualization of early hip pathology invisible on plain radiographs. METHOD: An MR arthrography of the hip with radial sequences is described. The standard MR technique is improved by 1) using a small flexible surface coil to show selectively the hip joint to be examined, 2) application of gadolinium intra-articularly and 3) by radial imaging sequences perpendicular to the true plane of the acetabulum. CONCLUSION: By this technique it is possible to achieve an undistorted image of each aspect of the acetabular rim. Regions of special interest can be defined and their pathologies possibly related to morphologies of the proximal end of the femur.

Acetabulum↗

CT arthrography and postoperative musculoskeletal imaging with multichannel computed tomography.

Multichannel computed tomography (MCCT) allows for rapid, thin slice acquisition and the ability to generate high mAs. This combination of features makes the modality ideal for MCCT arthrography, which requires thin, overlapping slices for robust reformatted images, and for imaging in the presence of orthopedic hardware, which necessitate high mAs. This article will explore these uses of MCCT.

Arthrography↗

[Wrist lesions in MRI arthrography compared with wrist arthroscopy].

BACKGROUND: Wrist arthroscopy is routinely used for diagnosis of ligamentous lesions to the wrist. Although it is very sensitive and specific, it is also more invasive than other available diagnostic techniques. METHOD: In a prospective trial, 125 patients (80 men, 45 women) 37 years old (+/- 12) with clinical evidence of wrist lesions were evaluated with direct wrist arthro MRI. Within 24 hours following direct arthro MRI wrist arthroscopy was performed. The surgeons and radiologists were not aware of the other results until completion of their investigation. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were determined. RESULTS: According to the MRI findings, lesions of the TFCC were suggested in 70 patients (56 % of all patients). In 65 cases this was confirmed by wrist arthroscopy. In the remaining 55 patients no TFCC lesions were detected by MRI. However in three cases TFCC lesions were found by arthroscopy. In the remaining 52 patients MRI accurately excluded TFCC lesions. There was a correlation of MRI and arthroscopy in detecting TFCC lesions in 93.6 %. Sensitivity was 94 %, specificity 89 %, positive predictive value 91 % and negative predictive value 93 %. Complete scapholunate ligament tears were detected by MRI in 12 (9.6 %) cases. Correlation with wrist arthroscopy was 99 %, sensitivity 92 %, specificity 100 %, positive and negative predictive value 100 % and 99 %, respectively. Accuracy for incomplete scapholunate lesions (n = 17, 13.6 %) and lunotriquetral tears (n = 4, 3.2 %) was poor (sensitivity 59 % and 25 %, specificity 100 % and 99 %). CONCLUSION: Though sensitivity of MRI arthrography approaches that of arthroscopy, it cannot replace it at the moment. However, it is a potent additional tool for wrist diagnosis if intraarticular contrast is used. It can facilitate diagnosis and indications for surgery of the wrist. It may make arthroscopic and more invasive interventions for diagnostic purposes avoidable in future.

Adult↗

[Arthroscopy of the wrist: compared results of MRT and arthrography and outcome in the arthroscopy -- an examination 1998 to 2003].

Between 1998 and 2004, 62 arthroscopies of the wrist were performed in the Vienna Danube Hospital. We examined if preoperative arthrography or magnet resonance tomography showed the same results concerning lesions of the discus ulnocarpalis or the scapholunate ligaments as did the arthroscopy and whether these two examinations are a good preoperative diagnostic instrument.

Adolescent↗

[Three-dimensional thickness and volume measurements of the knee joint cartilage using MRI: validation in an anatomical specimen by CT arthrography].

PURPOSE: In the present study we intended to validate knee joint cartilage volume and thickness measurements with MRI. METHODS: Ten fresh cadaver knees (age 29 to 64 yrs.) were sagittally imaged, using a fat-suppressed FLASH-3D sequence with a resolution of 2 x 0.31 x 0.31 mm3. Then, a contrast agent was injected and the specimens submitted to CT arthrography. From both modalities the patellar, femoral, and tibial cartilages were segmented semiautomatically and reconstructed three-dimensionally. The cartilage thickness was determined independently of the sectional plane, based on a "minimal distance algorithm". RESULTS: The volumes and the regional distribution patterns yielded a very high degree of similarity on direct comparison of both imaging modalities. The average volume error between MRI and CT was 3.8% (+/- 3.0%), the correlation 0.998, the slope of the regression line 1.04 and the gamma-intercept -80 mm3. The analysis yielded no significant differences between the two methods (Wilcoxon signed rank test, 5% level) in the patella, femur, medial, and lateral tibia. CONCLUSION: The results suggest that, based on a fat-suppressed FLASH sequence with high resolution and three-dimensional concepts of digital image analysis, the cartilage volume and thickness can be analysed non-invasively and with high accuracy by MRI.

Algorithms↗

MRI in the evaluation of patients with suspected instability of the shoulder joint including a comparison with CT-arthrography.

Thirty-two patients with clinical suspicion of shoulder instability were the subject of this assessment of MRI (1.5 T G. E. Signa) and its comparison with CT-arthrography (GE8800 and GE9800) of the shoulder. Twenty-seven patients had a final diagnosis established by arthroscopy and five by arthrotomy. The imaging examinations were interpreted independently by three radiologists blinded against history, surgical diagnosis and results of the compared test. The statistical analysis included ROC-curves, sensitivity, specificity and accuracy as well as predictive values. The significance of the comparative results was assessed by the McNemar Sign test. MRI showed significantly better diagnostic results in the evaluation of labral structures (sensitivity 85%, specificity 90%, accuracy 88%) and humeral head impression fractures (75, 82, 78 %). None of the tests were of sufficient diagnostic value to identify capsular abnormalities. CT and MRI results regarding the biceps tendon and loose bodies were similar, however, statistically not significant. MRI proved to be of high diagnostic value in the assessment of the unstable shoulder and compared favorably with CT-A.

Adolescent↗

[Lesions of the long head of the biceps--their pathogenesis and demonstration by imaging procedures (sonography, x-ray, arthrography and computed tomography)].

Because of unusual anatomy and function the long head of the biceps brachii (LHB) is often subject to pathologic changes. On reviewing 354 sonographies of the shoulder (7.5 MHz), it was found that 61 (= 17%) abnormal findings of the LHB were reported such as degenerative changes accompanying impingement stadium II and III (atrophy, hypertrophy, effusion), intracapsular ruptures, acute isolated tenosynovitis and bony changes of the sulcus (bony spurs, shallow and dysplastic sulcus with subluxation of the LHB). Each abnormal finding was confirmed by x-ray and arthrography (some via CT) and compared with sonographic report. There seems to be a strikingly high percentage of rotator cuff tears connected with lesions of the LHB and the reduced filling of the sheath of the LHB, if combined lesions were apparent elsewhere in the shoulder. We consider sonography to be the method of choice in the assessment of LHB injuries; in case of verified lesion of the LHB, other pathologic conditions elsewhere in the shoulder are likely.

Adolescent↗

[1.5 T MRI, arthrography and arthroscopy in the evaluation of knee lesions].

It has been previously demonstrated that MRI can show the knee joint non-invasively and without radiation. Forty-two patients with lesions of the knee were examined using 1.5 Tesla and flexible surface coils. The findings were compared with those of arthroscopy, arthrography and, where possible, with those at surgery. For the evaluation of cruciate ligament injuries, MRI proved to have a sensitivity of 100% and a specificity of 82% with an overall accuracy of 92%. Thirty-nine cruciate ligaments were correctly evaluated. Three times a false positive diagnosis was made. Examination of the menisci was less reliable. Sensitivity was 88% and specificity was 83% with an overall accuracy of 94%. Fifteen meniscus lesions were correctly diagnosed. Three times a false positive and twice a false negative diagnosis was made. Four of the five incorrect diagnoses concerned the posterior horn of the meniscus and three were situated laterally.

Adolescent↗

Evaluation of collateral ligament injuries of the metacarpophalangeal joints with magnetic resonance imaging and magnetic resonance arthrography.

Injuries of the collateral ligaments of the metacarpophalangeal (MCP) joints of the hand require accurate diagnosis and prompt treatment to prevent loss of function. The most common and well-known collateral ligament injury is injury to the ulnar collateral ligament of the first MCP joint of the hand, often referred to as a gamekeeper injury. Although less common, injuries involving the collateral ligaments of the second through fifth digits and the radial collateral ligament of the first digit also occur. The diagnosis of collateral ligament injury is often made clinically, however, magnetic resonance imaging and magnetic resonance arthrography of the MCP joints can be very useful in the evaluation of severity of the injury. This provides important information for the hand surgeon and aids in treatment planning. Imaging of the collateral ligaments requires small fields of view and several technical considerations can provide improved image quality. These factors will be discussed and illustrated in this article.

Arthrography↗

Evaluation of various contrast agents for improved arthrography.

In the canine knee joint the monomer methylglucamine iothalamate, the dimer methylglucamine iocarmate, and the nonionic contrast agent metrizamide were examined for use in arthrography. A total of 104 injections were performed with equal iodine concentrations (280-282 mg/ml) and volumes (4 ml) of the three contrast agents. These were evaluated using radiographic comparison and iodine estimations of the joint fluid at various times after injection. Radiographically the dimer was superior, followed by metrizamide and then the monomer. The greatest amount of total iodine within the joint fluid at various times after injection was found with the dimer. Iodine concentrations in the joint fluid were similar for the dimer and metrizamide, both greater than with the monomer.

Animals↗

Arthrography with Amipaque (metrizamide) and other contrast media. A roentgenographic and histologic evaluation in rabbits.

Arthrography of the knee joint was performed in 30 rabbits for comparison of Amipaque (metrizamide) with Urografin 60% (meglumine-sodium diatrizoate), Isopaque Amin (meglumine-calcium metrizoate), Conray Meglumin 282 (meglumine iothalamate) and Dimer-X (meglumine iocarmate). Films taken at regular intervals show longer contrast duration, and less hydrarthrosis after injection of Amipaque. Minimal focal inflammatory reaction in the synovial membrane is found in many cases when the animals are sacrificed 1 day or 7 days after the injections. No significant difference can be found between the contrast media, and similar changes are also seen after injection of physiologic saline.

Animals↗

Digital subtraction shoulder arthrography in determining site and size of rotator cuff tear.

RATIONALE AND OBJECTIVES: To evaluate the value of digital subtraction arthrographic techniques in assessing the precise size and site of rotator cuff tear. PATIENTS AND METHODS: Prospectively interpreted findings of 29 digital arthrographs were compared with results after surgery in 22 patients and with results after arthroscopy in 7 patients. RESULTS: Surgery or arthroscopy revealed 14 full-thickness and 2 partial-thickness tears. Digital subtraction arthrography showed 88% (14 of 16) of the rotator cuff tears, 86% (12 of 14) of the full-thickness tears, and 100% (2 of 2) of the partial-thickness tears. The site of a tear could be shown in 86% (12 of 14), but the size was evaluated to be less extensive than that seen at surgery in most tears (63%, 10 of 16). CONCLUSIONS: The site of tears could be demonstrated in supraspinatus tendon tears, but measurements of the size of the tears were accurate only in small full-thickness and in partial-thickness tears. Very anterior and posterior tears may not be diagnosed with this method, and postexercise films were necessary to avoid false-negative findings.

Adult↗

Partial thickness supraspinatus tears: diagnosis by magnetic resonance arthrography.

Two patients, with clinical symptoms of advanced impingement syndrome, presented for radiologic evaluation. The magnetic resonance (MR) images of each patient were interpreted as representing a full thickness tear of the supraspinatus tendon. Magnetic resonance arthrography was performed on both patients to further determine the extent of the tear. Using this technique, both patients were diagnosed correctly as having partial thickness tears; one on the articular surface and the other on the bursal surface of the tendon. This information is useful in surgical planning and in patient outcome.

Adult↗

MR arthrography of the shoulder: variants and pitfalls.

Use of magnetic resonance arthrography to evaluate pathologic conditions of the shoulder is becoming widespread. However, normal anatomy or anatomic variations can cause interpretive errors. The most common variations occur at the origins of the glenohumeral ligaments (GHLs) and the insertion of the joint capsule. Among the GHL variants, common origin of the superior and middle ligaments is the most frequent followed by thinning, thickening, or absence of a ligament, most often the middle one. Absence or thinning of one ligament is sometimes associated with thickening of another or changes in the size and shape of the anterior capsular recesses. Common normal variants of the labrum include foramen sublabrum (detachment of the anterosuperior labrum from the glenoid margin) and the Buford complex (absence of the anterosuperior labrum in association with a thick middle GHL). Pitfalls related to the arthrographic technique include (a) visualization of a deep sulcus between the insertion of the long head of the biceps tendon and the superior labrum and (b) an apparent type III capsular insertion due to overdistention of the capsule by injected contrast material.

Arthrography↗