Adam C. Zoga

Osteochondral Lesions of the Talus: Localization and Morphologic Data from 424 Patients Using a Novel Anatomical Grid Scheme

Background: The primary aim of this study was to evaluate the true incidence of osteochondral lesions on the talar dome by location and by morphologic characteristics on MRI. Because no universally accepted localization system for talar dome osteochondral lesions currently exists, we established a novel, nine-zone anatomical grid system on the talar dome for an accurate depiction of lesion location. Methods: We assigned nine zones to the talar dome articular surface in an equal 3 × 3 grid configuration. Zone 1 was the most anterior and medial, zone 3 was anterior and lateral, zone 7 was most posterior and medial, and zone 9 was the most posterior and lateral. The grid was designed with all nine zones being equal in surface area. Two observers reviewed MRI examinations of 428 ankles in 424 patients (211 males and 213 females; mean age 43 years; age range 6 to 85 years) with reported osteochondral talar lesions. We recorded the frequency of involvement and size of lesion for each zone. Statistical analyses were performed using ANOVA and Scheffe tests. Results: Four hundred and twenty-eight lesions were identified on MRI. The medial talar dome was more frequently involved (n = 269, 62%) than the lateral talar dome (n = 143, 34%). In the AP direction, the mid talar dome (equator) was much more frequently involved (n = 345, 80%) than the anterior (n = 25, 6%) or posterior (n = 58, 14%) thirds of the talar dome. Zone 4 (medial and mid) was most frequently involved (n = 227, 53%), and zone 6 (lateral and mid) was second most frequently involved (n = 110, 26%). Lesions in the medial third of the talar dome were significantly larger in surface area involvement and deeper than those at the lateral talar dome. Conclusions: Our established nine-grid scheme is a useful tool for localizing and characterizing osteochondral talar lesions, which are most frequently located in zone 4 at the medial talar dome, and second most in zone 6 at the lateral talar dome near its equator. Medial talar dome lesions are not only more common but are larger in surface area and in depth than lateral lesions. Posteromedial and anterolateral lesions rarely were found.

Athletic pubalgia and the "sports hernia": MR imaging findings

PURPOSE To retrospectively determine the sensitivity and specificity of magnetic resonance (MR) imaging findings in patients with clinical athletic pubalgia, with either surgical or physical examination findings as the reference standard. MATERIALS AND METHODS Institutional review board approval was granted for this HIPAA-compliant study, and informed consent was waived. MR imaging studies in 141 patients (134 male patients, seven female patients; mean age, 30.1 years; range, 17-71 years) who had been referred to a subspecialist because of groin pain were reviewed for findings including hernia, pubic bone marrow edema, secondary cleft sign, and rectus abdominis and adductor tendon injury. MR imaging findings were compared with surgical findings for 102 patients, physical examination findings for all 141 patients, and MR imaging findings in an asymptomatic control group of 25 men (mean age, 29.8 years; range, 18-39 years). Sensitivity and specificity of MR imaging for rectus abdominis and adductor tendon injury were determined by using a chi(2) analysis, and significance of the findings was analyzed with an unpaired Student t test. Disease patterns seen at MR imaging were compared with those reported in the surgical and sports medicine literature. RESULTS One hundred thirty-eight (98%) of 141 patients had findings at MR imaging that could cause groin pain. Compared with surgery, MR imaging had a sensitivity and specificity, respectively, of 68% and 100% for rectus abdominis tendon injury and 86% and 89% for adductor tendon injury. Injury in each of these structures was significantly more common in the patient group than in the control group (P < .001). Only two patients had hernias at surgery. At MR imaging, injury or disease could be fit into distinct groups, including osteitis pubis, adductor compartment injury, rectus abdominis tendon injury, and injury or disease remote from the pubic symphysis. Patients with injury involving the rectus abdominis insertion were most likely to go on to surgical pelvic floor repair. CONCLUSION MR imaging depicts patterns of findings in patients with athletic pubalgia, including rectus abdominis insertional injury, thigh adductor injury, and articular diseases at the pubic symphysis (osteitis pubis).

Experience with "sports hernia" spanning two decades.

Objective and Background:Athletic pubalgia (AP) is a leading cause of athlete loss from competitive sports. Commonly misnamed “sports hernia,” AP is a set of pelvic injuries involving the abdominal and pelvic musculature outside the ball-and-socket hip joint and on both sides of the pubic symphysis. Prospective studies show that timely intervention and appropriate repair of selected injuries results in greater than 95% success. Methods:The senior author reviewed his experience with 8490 patients and 5460 operations, looking primarily at the changes in patient characteristics over the last 2 decades and at some of the advances. Results:Female proportion, age, numbers of sports, and soft tissue structures involved have all increased as have the number of syndromes identified and number of operations. MRI has improved greatly for both the diagnosis of hip and nonhip pathology in the pelvis. Increased understanding has led also to new rehabilitation and performance protocols. Conclusions:Better understanding and recognition of the injuries has led to more satisfactory care and returned many athletes to successful careers, which has had a major impact on modern sport.

Prediction of Midfoot Instability in the Subtle Lisfranc Injury: Comparison of Magnetic Resonance Imaging with Intraoperative Findings

BACKGROUND The objective of the present study was to assess the utility of magnetic resonance imaging for the diagnosis of an injury to the Lisfranc and adjacent ligaments and to determine whether conventional magnetic resonance imaging is a reliable diagnostic tool, with manual stress radiographic evaluation with the patient under anesthesia and surgical findings being used as a reference standard. METHODS Magnetic resonance images of twenty-one feet in twenty patients (ten women and ten men with a mean age of 33.6 years [range, twenty to fifty-six years]) were evaluated with regard to the integrity of the dorsal and plantar bundles of the Lisfranc ligament, the plantar tarsal-metatarsal ligaments, and the medial-middle cuneiform ligament. Furthermore, the presence of fluid along the first metatarsal base and the presence of fractures also were evaluated. Radiographic observations were compared with intraoperative findings with respect to the stability of the Lisfranc joint, and logistic regression was used to find the best predictors of Lisfranc joint instability. RESULTS Intraoperatively, seventeen unstable and four stable Lisfranc joints were identified. The strongest predictor of instability was disruption of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals (the pC1-M2M3 ligament), with a sensitivity, specificity, and positive predictive value of 94%, 75%, and 94%, respectively. Nineteen (90%) of the twenty-one Lisfranc joint complexes were correctly classified on magnetic resonance imaging; in one case an intraoperatively stable Lisfranc joint complex was interpreted as unstable on magnetic resonance imaging, and in another case an intraoperatively unstable Lisfranc joint complex was interpreted as stable on magnetic resonance imaging. The majority (eighteen) of the twenty-one feet demonstrated disruption of the second plantar tarsal-metatarsal ligament, which had little clinical correlation with instability. CONCLUSIONS Magnetic resonance imaging is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when the plantar Lisfranc ligament bundle is used as a predictor. Rupture or grade-2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals is highly suggestive of an unstable midfoot, for which surgical stabilization has been recommended. The appearance of a normal ligament is suggestive of a stable midfoot, and documentation of its integrity may obviate the need for a manual stress radiographic evaluation under anesthesia for a patient with equivocal clinical and radiographic examinations.

MR Imaging of the Diabetic Foot

Abnormalities of the peripheral nervous, vascular, and immune systems contribute to the development of numerous foot and ankle pathologies in the diabetic population. Although radiographs remain the most practical first-line imaging tool, magnetic resonance (MR) is the tertiary imaging modality of choice, allowing for optimal assessment of bone and soft tissue abnormalities. MR allows for the accurate distinction between osteomyelitis/septic arthritis and neuropathic osteoarthropathy. Furthermore, it provides an excellent presurgical anatomic road map of involved tissues and devitalized skin to ensure successful limited amputations when required. Signal abnormality in the postoperative foot aids in the diagnosis of recurrent infection.

Hamstring Injuries in Professional Football Players: Magnetic Resonance Imaging Correlation With Return to Play

Background: Magnetic resonance imaging (MRI) allows for detailed evaluation of hamstring injuries; however, there is no classification that allows prediction of return to play. Purpose: To correlate time for return to play in professional football players with MRI findings after acute hamstring strains and to create an MRI scoring scale predictive of return to sports. Study Design: Descriptive epidemiologic study. Methods: Thirty-eight professional football players (43 cases) sustained acute hamstring strains with MRI evaluation. Records were retrospectively reviewed, and MRIs were evaluated by 2 musculoskeletal radiologists, graded with a traditional radiologic grade, and scored with a new MRI score. Results were correlated with games missed. Results: Players missed 2.6 ± 3.1 games. Based on MRI, the hamstring injury involved the biceps femoris long head in 34 cases and the proximal and distal hamstrings in 25 and 22 cases, respectively. When < 50% of the muscle was involved, the average number of games missed was 1.8; if > 75%, then 3.2. Ten players had retraction, missing 5.5 games. By MRI, grade I injuries yielded an average of 1.1 missed games; grade II, 1.7; and grade III, 6.4. Players who missed 0 or 1 game had an MRI score of 8.2; 2 or 3 games, 11.1; and 4 or more games, 13.9. Conclusions: Rapid return to play (< 1 week) occurred with isolated long head of biceps femoris injures with < 50% of involvement and minimal perimuscular edema, correlating to grade I radiologic strain (MRI score < 10). Prolonged recovery (missing > 2 or 3 games) occurs with multiple muscle injury, injuries distal to musculotendinous junction, short head of biceps injury, > 75% involvement, retraction, circumferential edema, and grade III radiologic strain (MRI score > 15). Clinical Relevance: MRI grade and this new MRI score are useful in determining severity of injury and games missed—and, ideally, predicting time missed from sports.

MRI findings in bipartite patella

PurposeBipartite patella is a known cause of anterior knee pain. Our purpose was to detail the magnetic resonance imaging (MRI) features of bipartite patella in a retrospective cohort of patients imaged at our institution.Materials and methodsMRI exams from 53 patients with findings of bipartite patella were evaluated to assess for the presence of bone marrow edema within the bipartite fragment and for the presence of abnormal signal across the synchondrosis or pseudarthrosis. Any other significant knee pathology seen at MRI was also recorded. We also reviewed 400 consecutive knee MRI studies to determine the MRI prevalence of bipartite patella.ResultsOf the 53 patients with bipartite patella 40 (75%) were male; 35 (66%) had edema within the bipartite fragment. Of the 18 with no edema an alternative explanation for knee pain was found in 13 (72%). Edema within the bipartite fragment was the sole finding in 26 of 53 (49%) patients. Bipartite patella was seen in 3 (0.7%) of 400 patients.ConclusionIn patients with bipartite patella at knee MRI, bone marrow edema within the bipartite fragment was the sole finding on knee MRI in almost half of the patients in our series.

Osteochondral Lesions of the Distal Tibial Plafond: Localization and Morphologic Characteristics with an Anatomical Grid:

Background: The aim of this study was to evaluate the incidence and morphologic characteristics of osteochondral lesions of the distal tibial plafond (OLTP) by location and morphologic characteristics on MRI. Material and Methods: We assigned 9 zones to the distal tibial plafond articular surface in an equal 3×3 grid configuration. Zone 1 was the most anterior and medial, zone 3 was anterior and lateral, zone 7 was most posterior and medial, and zone 9 was the most posterior and lateral. The grid was designed with all 9 zones being equal in surface area. Two observers reviewed MRI examinations of 38 patients (12 males and 26 females; mean age, 38.7 years; age range, 10 to 68 years) with reported OLTPs. We recorded the frequency of involvement and size of lesion for each zone. A chart review was performed. Results: Of the 38 OLTP found in this study, 14 (37%) of the lesions were on the medial tibial plafond [zones 1, 4 and 7] and 11 (29%) involved the lateral tibial plafond [zones 3, 6 and 9]; 13 lesions (34%) localized to the center third of the plafond [zones 2, 5 and 8]. Nine of the lesions (24%) were on the anterior tibial plafond [zones 1, 2 and 3], 15 lesions (39%) predominately involved the posterior plafond [zones 7, 8 and 9], and 14 lesions (37%) localized to the central third of the plafond [zones 4, 5 and 6]. The medial central tibial plafond was most frequently involved site with 8 of the 38 (21%) lesions located there; the posterior medial tibial plafond was second most frequently involved with six of the 38 lesions (16%). Six of 38 ankles had both a talar osteochondral lesion and an OLTP. Of these, only one was a ‘kissing’ lesion. Chart review revealed that all subjects had ankle pain at time of MRI examination. Conclusion: We conclude that osteochondral lesions of the distal tibial plafond must be considered in the differential diagnosis of patients with symptomatic ankles and that no location had a significantly higher incidence.

Posteromedial Elbow Impingement: Magnetic Resonance Imaging Findings in Overhead Throwing Athletes and Results of Arthroscopic Treatment

PURPOSE The purpose of this study was to define the magnetic resonance imaging (MRI) pattern and assess the results of arthroscopic treatment of posteromedial elbow impingement in overhead throwers. METHODS Over an 8-year period, 9 throwing athletes diagnosed with posteromedial elbow impingement were retrospectively identified. All patients had either a noncontrast or direct arthrogram-MRI study that was reviewed by a single, fellowship-trained musculoskeletal radiologist blinded to the clinical diagnosis. Arthroscopic treatment included debridement of posteromedial synovitis, loose body removal, and excision of the olecranon spur. All patients underwent a physical examination and completion of the Andrews-Carson scale at a mean of 68 months (range, 25 to 112 months). RESULTS All patients were male, with a mean age of 21.0 years (range, 17 to 34 years). The dominant arm was affected in all patients. The mean length of symptoms before surgery was 9 months (range, 5 to 24 months). At MRI, a reproducible pattern of pathology was noted. All patients had pathology at the articular surfaces of the posterior trochlea and the anterior, medial olecranon. The findings ranged from abnormal edema-like signal in the hyaline cartilage to cartilage defects and subjacent, subchondral bone marrow edema. Findings at surgery included posteromedial synovitis and olecranon spurring in all patients and loose bodies in 3 patients. On the basis of the Andrews-Carson scale, the subjective and objective outcome was considered excellent in 7 patients and good in 2. CONCLUSIONS Posteromedial elbow impingement is a source of disability in the overhead throwing athlete. Correlation of history and physical examination with imaging findings is essential to confirm the diagnosis. This study indicates that MRI identifies a reproducible pattern of pathology in throwing athletes with this disorder. These MRI findings correlate highly with arthroscopic evaluation. Arthroscopic debridement, olecranon spur excision, and loose body removal allow return to throwing sports and reliable subjective and objective results in carefully selected patients.

Treatment of massive and recurrent rotator cuff tears augmented with a poly-l-lactide graft, a preliminary study

BACKGROUND The incidence of failed rotator cuff repairs remains high, especially in the setting of massive tears or revision repairs. The purpose of this study was to evaluate patient outcomes and repair integrity after augmentation with the repair patch, a poly-l-lactide synthetic polymer. METHODS Sixteen consecutive patients with massive or recurrent rotator cuff tears underwent open repair with synthetic poly-l-lactide patch augmentation. Two patients required the patch to bridge defects, and 1 patient retore after a motor vehicle accident and had revision surgery at another institution. The 13 remaining patients were retrospectively evaluated from 1.2 to 1.7 years (average, 1.5 years) after surgery by PENN, American Shoulder and Elbow Surgeons, and Single Assessment Numeric Evaluation scores. Magnetic resonance imaging was used to examine the integrity of the repair at a minimum of 1 year of follow-up. RESULTS The mean age was 57.3 years (42-68 years). Five patients (38%) had an intact rotator cuff at the time of follow-up. The remaining patients (62%) had full-thickness tears. PENN scores significantly improved from a preoperative score of 50.9 to 77.6 (P < .005). American Shoulder and Elbow Surgeons scores significantly improved from 32.8 to 74.2 (P = .0001). Single Assessment Numeric Evaluation scores at latest follow-up were 76.2. CONCLUSION Poly-l-lactide repair patch augmentation of massive and recurrent large to massive rotator cuff tears demonstrates significant improvement in shoulder outcome measures for this difficult population, despite a retear rate of 62%. Further investigation with larger, prospective long-term studies is needed to determine whether this technique provides a true benefit compared with traditional, nonaugmented repair.