Evangelia E. Vassalou

MR imaging of transient osteoporosis of the hip: An update on 155 hip joints

PURPOSE Transient osteoporosis of the hip (TOH) presents with acute onset pain and bone marrow edema (BMe) on MR imaging. The purpose of this study is to revise the MR imaging characteristics of TOH by analyzing the data derived from 155 hip examinations. We also sought to explore the relationship between the duration of symptoms and the presence of sparing and subchondral fractures. MATERIALS AND METHODS MR images of 155 hips (141 TOH patients) were retrospectively evaluated for the presence of insufficiency fractures and the morphology of BMe. Sparing of the medial bone marrow of the femoral head was recorded together with demographic and clinical data. Progression to regional migratory osteoporosis (RMO) and postpartum cases were also recorded. RESULTS Our population consisted of 76.4% male and 23.6% female patients. RMO progression was recorded in 19.4% and 4 postpartum cases displayed bilateral disease. Sparing of the medial bone marrow was present at 87.7% of patients and disappeared as the disease progressed (P=0.005). BMe was restricted within the femoral head in 11.0%, extended to the femoral neck in 40% and to the femoral shaft in 49% of the cases studied. Subchondral fractures were present at 48.7% of the hips. CONCLUSION This study describes TOH patient characteristics, the MR imaging findings (BMe pattern, microfractures), their association with symptom duration and the chance of progressing to RMO.

Rotational Knee Laxity in Anterior Cruciate Ligament Deficiency: An Additional Secondary Sign on MRI.

OBJECTIVE The objective of this study was to evaluate the accuracy of tibial rotation measurement as a secondary sign for diagnosing anterior cruciate ligament (ACL) tears with the use of MRI. MATERIALS AND METHODS A total of 893 MRI studies were retrospectively reviewed, and 239 patients were identified as having either an intact ACL (group 1; n = 182), an arthroscopically confirmed acutely torn ACL (group 2; n = 22), or a chronically torn ACL (group 3; n = 35). Tibial rotation was estimated by measuring the femorotibial angle (FTA). RESULTS The mean (± SD) FTA was significantly higher in group 2 (10.7° ± 4.8°) and group 3 (11° ± 5.5°) than in group 1 (3.2° ± 3.3°) (p < 0.001, for all cases). An FTA of 4.9° was the optimal threshold (sensitivity, 93%; specificity, 80%) for separating completely torn ACLs from intact ACLs. An FTA ranging from 4.9° to 5.5° (sensitivity, 95%; specificity, 80%) indicated a complete acute ACL tear, whereas an FTA of 5.6° or greater (sensitivity, 91.4%; specificity, 83.5%) suggested a complete chronic ACL tear. CONCLUSION An increased FTA indicates alteration in the femorotibial anatomic relationship and could be of value in assessing ACL tears in patients with equivocal signs on MRI.

Piriformis muscle syndrome: A cross-sectional imaging study in 116 patients and evaluation of therapeutic outcome

AbstractObjectivesTo increase the clinical awareness of piriformis muscle syndrome (PMs) by reporting cross-sectional imaging findings, the clinical impact of imaging studies and treatment outcome.MethodsWithin a 10-year-period, 116 patients referred for radiological evaluation of clinically suspected PMs, with excluded lumbar pathology related to symptomatology, were prospectively studied with MRI and/or computed tomography (CT). Piriformis muscle (PM), sciatic nerve (SN), piriformis region and sacroiliac joints were evaluated. PMs was categorised into primary/secondary, according to a reported classification system. Treatment decisions were recorded. Outcome was categorised using a 3-point-scale.ResultsSeventy-four patients (63.8%) exhibited pathologies related to PMs. Primary causes were detected in 12 and secondary in 62 patients. PM enlargement was found in 45.9% of patients, abnormal PM signal intensity/density in 40.5% and sciatic neuritis in 25.7%. Space-occupying lesions represented the most common related pathology. Treatment proved effective in 5/8 patients with primary and 34/51 patients with secondary PMs. In 34 patients, imaging revealed an unknown underlying medical condition and altered treatment planning.ConclusionsSecondary PMs aetiologies appear to prevail. In suspected PMs, PM enlargement represented the most common imaging finding and space-occupying lesions the leading cause. Imaging had the potential to alter treatment decisions.Key Points• In clinically suspected PMs cross-sectional imaging may reveal variable pathology. • Secondary PMs aetiologies appeared to be more common than primary. • PM enlargement represented the most common imaging finding in clinically suspected PMs. • Space-occupying lesions in the piriformis region represented the leading cause of PMs. • In clinically suspected PMs cross-sectional imaging may alter treatment planning.

Hydroxyapatite deposition disease around the hip: outcomes of CT-guided treatment.

PURPOSE Hydroxyapatite deposition disease (HADD) around the hip joint is a self-limiting condition usually treated conservatively. The aim of the present study is to directly compare the outcomes of CT-guided and conservative treatments in cases of refractory hip HADD. METHODS Two groups of patients with refractory hip HADD were prospectively constructed from a pool of 484 patients referred for greater trochanter pain syndrome, based on the presence of calcifications around the hip and the failure of conservative treatment. Study group included 22 hips, which underwent CT-guided barbotage and steroid injection treatment, whereas control group consisted of 28 hips that were treated conservatively. Evaluation of the outcome of both groups was performed over a one-year follow-up period with the use of a score measuring clinical improvement in terms of pain and functional impairment. RESULTS Three weeks after the initiation of treatment, study group exhibited significantly higher scores compared with the control group (P < 0.001). Improvement scores of the control group were similar to the study group after three months of treatment (P > 0.1). CONCLUSION CT-guided treatment provides relief of debilitating symptoms in the acute phase.

Modified Lung Ultrasonographic Technique for Evaluation of Idiopathic Pulmonary Fibrosis: Lateral Decubitus Position

To compare lung ultrasonography (US) in the sitting or supine positions and the lateral decubitus position, with regard to the feasibility, duration, patient convenience, and assessment of B‐lines, in patients with idiopathic pulmonary fibrosis.

Imaging of Impingement Syndromes around the Hip Joint

Impingement syndromes are increasingly recognised as significant causes of hip pain and dysfunction. A broad spectrum of intraarticular and extraarticular conditions has been implicated in their pathophysiology. Physical examination is often inconclusive as clinical findings may be unclear or misleading, often simulating other disorders. With current improvements in imaging techniques and better understanding of hip impingement related pathomechanisms, these entities can be accurately diagnosed. In addition, preoperative imaging has allowed for targeted treatment planning. This article provides an overview of the various types of hip impingement, including femoroacetabular impingement, ischiofemoral impingement, snapping hip syndrome, greater trochanteric-pelvic and subspine impingement. Current literature data regarding their pathogenesis, clinical manifestation and imaging work-up are discussed.

Lung Ultrasonography in Patients With Idiopathic Pulmonary Fibrosis: Evaluation of a Simplified Protocol With High‐Resolution Computed Tomographic Correlation

To compare a simplified ultrasonographic (US) protocol in 2 patient positions with the same‐positioned comprehensive US assessments and high‐resolution computed tomographic (CT) findings in patients with idiopathic pulmonary fibrosis.

Response to Letter to the Editor on ‘Piriformis muscle syndrome: A cross-sectional imaging study in 116 patients and evaluation of therapeutic outcome’

Dear Editor, We would like to thank the author(s) of the Letter to the Editor for their interest in our recently published scientific paper, ‘Piriformis muscle syndrome: A cross-sectional imaging study in 116 patients and evaluation of therapeutic outcome’ [1]. We sincerely appreciate the constructive criticism, which promotes a productive discussion on a challenging clinical entity. We hereby respond to the main queries in the letter. The author(s) of the letter suggest that a local piriformis muscle (PM) injection test should have preceded any imaging investigation in patients with clinically suspected piriformis muscle syndrome (PMs), in order to confirm such a diagnosis. We strongly agree with the author(s) that such a minimally invasive procedure serves as a valuable tool in confirming the source of symptoms and providing pain relief, not necessarily permanent, in patients with clinically suspected PMs. However, this approach cannot either rule out the presence of an underlying pathology, manifesting as PMs, or identify the type of the potential causative lesions. The exclusion or identification of any potential underlying pathology related to PMs is of utmost importance as PMs appears to be related to the presence of a precipitating cause in a large percentage of patients [2–7]. The results of our prospective study [1] regarding the role of crosssectional imaging in PMs are similar to other reports [8]. We totally agree on that pain related to PMs may be of myofascial origin as well; however, contrary to the author(s), we do not support that this represents the case in the majority of patients and, to the best of our knowledge, the incidence of myosfascial pain as a cause of PMs remains to be defined. In any case, myofascial pain represents a diagnosis of exclusion which can be safely claimed, given that the presence of any potential lesions related to PMs has been excluded. Thus, we insist that the diagnostic algorithm in patients with clinically suspected PMs should be structured as follows: (1) detailed clinical examination; (2) exclusion of lumbar pathology via imaging; (3) exclusion or identification of underlying precipitating causes via pelvic magnetic resonance (MR) imaging and/or computed tomography (CT). In our opinion, a local PM injection test should be retained for patients in whom the proposed investigation algorithm does not establish a causative factor. Adding to that, we consider that the ability ofMR imaging and/or CT to identify an unknown underlying medical condition, manifested as PMs,may alter treatment planning in a significant proportion of patients (34 patients) in our study [1]. This highlights the clinical impact and role of cross-sectional imaging in PMs. In our practice, we routinely perform a CT-guided PM injection test when imaging is negative, but this was not the aim of our study. It is not evidence-based to perform PM local injection in patients without previous imaging investigation, as in the study cited by author(s) [9]. Finally, local injection without previous imaging induces a risk for complications, i.e. haemorrhage, infectious and neoplastic dissemination, or a delay in diagnosis, i.e. axial spondyloarthropathy. Based on the above, local PM injection test could ideally have been performed in the 42/116 patients with clinically suspected PMs and negative imaging studies. As stated in our limitations’ paragraph, such an approach was not attempted in our study, which may partially account for the inability to confirm the aetiology of symptoms in this subgroup [1]. In agreement with the author(s), we believe that at least a subgroup of these 42 patients may have had pain of myofascial origin, whereas other potential causes of symptoms include dynamic sciatic nerve entrapment by the PM and PM spasm [2]. On the other hand, it has to be pointed out that our study primarily aims to assess the role of the radiologist in the diagnosis of PMs by This reply refers to the comment available at https://doi.org/10.1007/ s00330-018-5554-4

Paroxysmal cough and left sacroiliac joint pain in a 50-year-old Caucasian man

A 50-year-old Caucasian man who was a lifelong nonsmoker presented with a 3-year history of paroxysmal dry cough, fatigue, nonspecific myalgias, muscle weakness of the lower extremities and left sacroiliac joint pain. Initially, he was reviewed by a pulmonologist and subsequently he was referred to the Dept of Thoracic Medicine (Heraklion University Hospital, Heraklion, Greece) for further investigation. His medical history was remarkable for the presence of arterial hypertension on treatment with amlodipine and irbesartan. Can you diagnose this patient with pulmonary symptoms, thoracic and laboratory test abnormalities and sacroiliac joint pain? http://ow.ly/LPyy30kaViz

Morel-Lavallée Lesions of the Knee: MRI Findings Compared With Cadaveric Study Findings

OBJECTIVE The purpose of this study is to describe the MRI findings and treatment decisions and outcome for Morel-Lavallée lesions (MLLs) of the knee and to investigate whether evidence exists to support an increased frequency of such lesions on the medial or lateral side by performing a cadaveric experiment. MATERIALS AND METHODS In a 4-year period, 24 MRI studies of 24 consecutive patients (16 male patients and eight female patients) with knee MLLs were retrospectively reviewed. Patient demographic characteristics, treatment decisions and outcome, and associated injuries were recorded. The location of the MLL was categorized as medial, lateral, or global. Lesions were categorized according to an established MRI classification. During the cadaveric experiment, the compartmental pressures of the medial or lateral aspect of the knee were monitored in 20 cadaveric knees. The chi-square test, t test, and Pearson correlation were used for statistical analysis. RESULTS MLLs were located medially in 16 patients, laterally in two patients, and globally in six patients. The medial location was significantly more common than a lateral or global location (p < 0.05). MLLs were classified as type I in 14 patients, type II in eight patients, and type III in two patients. MRI type was correlated with the chronicity of injury (r2 = 0.614; p = 0.0014). Fractures were the most common associated injuries, occurring in seven of 24 patients. In 17 patients, all of whom had conservatively treated type I or type II lesions, complete resolution of the MLL occurred. The maximum compartmental pressures were significantly higher on the lateral side than on the medial side (p < 0.0001). CONCLUSION Knee MLLs have a predilection for the medial side, which may be attributed to the lower resistance in this location, and they have variable patterns on MRI, which correlate with chronicity. Conservative treatment of type I and II lesions seems effective.