Kyu-Sung Kwack

Septic Arthritis Versus Transient Synovitis of the Hip: Gadolinium-Enhanced MRI Finding of Decreased Perfusion at the Femoral Epiphysis

OBJECTIVE The purpose of this study was to identify differences in the MRI findings of septic arthritis and transient synovitis in patients with nontraumatic acute hip pain and hip effusion. MATERIALS AND METHODS The MRI findings in nine patients with septic arthritis and 11 with transient synovitis were reviewed retrospectively. This study was approved by our institutional review board. The diagnoses were based on findings at physical examination, laboratory studies, and joint aspiration and bacteriologic study. The MRI findings were analyzed with emphasis on the grade of joint effusion, alterations in signal intensity in the soft tissues and bone marrow, and the presence of decreased perfusion at the femoral head. RESULTS Low signal intensity on fat-suppressed gadolinium-enhanced T1-weighted coronal MRI suggesting decreased perfusion at the femoral head of the affected hip joint was seen in eight of nine patients with septic arthritis and in two of 11 patients with transient synovitis. Statistically reliable differences (p = 0.005) were found between the two groups. Alterations in signal intensity in the bone marrow were seen in three patients with septic arthritis but in none of the patients with transient synovitis. Decreased perfusion on fat-suppressed gadolinium-enhanced coronal T1-weighted MRI was seen in the six patients with septic arthritis who did not have alterations in signal intensity involving the bone marrow. CONCLUSION Decreased perfusion at the femoral epiphysis on fat-suppressed gadolinium-enhanced coronal T1-weighted MRI is useful for differentiating septic arthritis from transient synovitis.

Optimal Dose of Intra-articular Corticosteroids for Adhesive Capsulitis A Randomized, Triple-Blind, Placebo-Controlled Trial

Background: Intra-articular corticosteroid injection is a commonly used therapy for adhesive capsulitis, but there are only few studies that compare the efficacy of corticosteroids according to different doses. Purpose: To determine whether intra-articular injections with a high-dose corticosteroid improves pain and function in patients with adhesive capsulitis better than a low dose or a placebo. Study Design: Randomized controlled clinical trial; Level of evidence, 1. Methods: Participants (n = 53) with primary adhesive capsulitis in the freezing stage were randomly assigned to receive ultrasound-guided intra-articular injections with 40 mg triamcinolone acetonide (high-dose group, n = 20), 20 mg triamcinolone acetonide (low-dose group, n = 20), or placebo (n = 13). After a single injection, participants were all instructed to carry out a home exercise program. The outcome measures included the Shoulder Pain and Disability Index (SPADI), visual analog scale (VAS) for average shoulder pain level, and passive range of motion including flexion, abduction, extension, external rotation, and internal rotation before treatment and at weeks 1, 3, 6, and 12 after treatment. Results: There were no significant differences in demographic and clinical characteristics at baseline between the 3 groups. Repeated-measures analysis of variance and post hoc tests showed improvement in SPADI and VAS scores and in flexion, abduction, and internal rotation especially for the low- and high-dose groups compared with the placebo. Yet, no significant difference was found between the 2 different corticosteroid dose groups. Conclusion: We assessed the efficacy of corticosteroid injections according to 2 different doses that are most widely used in intra-articular injections for adhesive capsulitis. This study shows that there were no significant differences between the high- and low-dose corticosteroid groups, indicating the preferred use of a low dose in the initial stage.

Usefulness of Dynamic Contrast-Enhanced MRI in Differentiating Between Septic Arthritis and Transient Synovitis in the Hip Joint

OBJECTIVE The purpose of this study was to show the usefulness of dynamic contrast-enhanced MRI (DCE-MRI) and to determine the optimal time window in MRI for differentiating between septic arthritis and transient synovitis in painful hip joints. MATERIALS AND METHODS Eighteen patients who underwent DCE-MRI were enrolled, and the final diagnoses were septic arthritis (n = 7) and transient synovitis (n = 11). The enhancement patterns of DCE-MRI were dichotomized according to the shape of the time-signal intensity curves. The time at the maximal difference in the signal intensity between two time-signal intensity curves of both femoral heads was recorded. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. Receiver operating characteristic curves were calculated. RESULTS Six of seven patients with septic arthritis in the hip joint had decreased enhancement during the early phase of DCE-MRI. The enhancement difference between the two patient groups was statistically significant (p = 0.0498). The time at the maximal difference in the signal intensity between two time-signal intensity curves of both femoral heads was approximately 3.5 minutes. The area under the receiver operating characteristic curve for predicting septic arthritis was 0.792. CONCLUSION DCE-MRI is useful in differentiating between septic hip arthritis and transient synovitis. If static contrast-enhanced coronal MRI is used, the optimal time for the acquisition of contrast-enhanced coronal MRI is approximately 3.5 minutes.

Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial.

OBJECTIVE To determine whether subacromial injection with high-dose corticosteroid in patients with periarticular shoulder disorders is better than low-dose corticosteroid or placebo in improving pain, function, and active range of motion (AROM). DESIGN Multicenter, randomized, triple-blind, placebo-controlled trial. SETTING Primary (n=2) and university-affiliated (n=1) tertiary-care hospitals. PARTICIPANTS Volunteers (N=79) with periarticular shoulder disorders with at least 1 months duration of pain. INTERVENTION Participants were randomly assigned to receive ultrasound-guided subacromial injection with triamcinolone acetonide, 40 or 20mg, or placebo. After a single injection, participants were followed up for 8 weeks. MAIN OUTCOME MEASURES Visual analog scale (VAS) of average shoulder pain level during the past 1 week, Shoulder Disability Questionnaire (SDQ), and angles of shoulder AROM (including flexion, abduction, external rotation, internal rotation) pre- and posttreatment at weeks 2, 4, and 8. RESULTS There were no significant differences among the 3 groups (triamcinolone acetonide, 40mg, group 1, n=27; triamcinolone acetonide, 20mg, group 2, n=25; placebo, group 3, n=27) in terms of demographic and clinical characteristics at baseline. (1) Within-group comparison: VAS score, SDQ score, and AROM for groups 1 and 2 significantly improved at weeks 2, 4, and 8 (P<.0167). However, there was no difference in VAS score, SDQ score, and AROM scores for group 3. (2) Between-group comparison: significant differences in VAS score, SDQ score, and abduction, external rotation, and internal rotation of AROM were shown between groups 1 and 2 and group 3 at weeks 2, 4, and 8 (P<.05). CONCLUSIONS This was the first study to assess the efficacy of corticosteroid according to 2 different doses, which are the most widely used in subacromial injection for participants with periarticular shoulder disorders. This study showed no significant differences between the high- (triamcinolone acetonide, 40mg) and low-dose (20mg) corticosteroid groups, indicating preferred use of a low dose at the initial stage.

Is the Anterior Tibial Artery Safe During Ankle Arthroscopy? Anatomic Analysis of the Anterior Tibial Artery at the Ankle Joint by Magnetic Resonance Imaging

Background: Pseudoaneurysm of the anterior tibial artery (ATA) after ankle arthroscopy is an uncommon complication but can cause unexpected consequences. However, its contributing factor is not fully understood. Hypothesis: Anatomic factors, such as ATA variations and the distance between the ATA and joint capsule, may contribute to the occurrence of pseudoaneurysm. Study Design: Case series; Level of evidence, 4. Methods: The magnetic resonance images and medical records of 358 ankle cases were analyzed. According to locations of the ATA in relation to the peroneus tertius (PT) and the extensor digitorum longus (EDL) tendon on axial magnetic resonance imaging, patients were classified as type 1 (safe type), type 2 (increased risk type), or type 3 (high-risk type). In addition, distances between the anterior joint capsule and the ATA were measured to evaluate the thickness of the anterior fat pad, which contains the ATA and anterior compartment tendons. Results: In 336 cases (93.8%), the ATA was located medial to the EDL (type 1, safe). In 7 cases (2.0%), the ATA was located lateral to the EDL and PT tendon (type 2, increased risk); and in 15 cases (4.2%), the branching artery was observed lateral to the EDL and PT tendon and the ATA was in the normal position (type 3, high risk). The mean distance between the anterior joint capsule and the ATA was 2.3 ± 1.1 mm. Conclusion: In 22 (6.2%) of the 358 cases, the ATA and its branches were located near the anterolateral ankle portal, which introduces the risk of vascular damage during arthroscopic surgery. Furthermore, the mean distance between the ATA and the joint capsule was only 2.3 ± 1.1 mm, and thus the ATA is very close to the anterior working space of the ankle joint. Careful preoperative evaluation and an intra-articular procedure may reduce the risk of vascular complications attributable to ankle arthroscopy.

Comparison Study of Intraarticular and Intravenous Gadolinium-Enhanced Magnetic Resonance Imaging of Cartilage in a Canine Model

Background: Magnetic resonance (MR) imaging and measurement of glycosaminoglycan (GAG) have potential for characterization of hyaline articular cartilage. Recently, some reports have demonstrated the potential of direct administration of contrast media for MR imaging of cartilage. Purpose: To prove the feasibility of intraarticular gadolinium-enhanced MR imaging of cartilage (iGEMRIC) and T1 relaxation mapping of the articular cartilage in vivo with intraarticular injection of Gd-DTPA2−. Material and Methods: Five healthy beagle dogs underwent MR imaging and T1 relaxation mapping of the knee joints of both hind legs. The delayed gadolinium-enhanced MR imaging of cartilage (dGEMRIC) and iGEMRIC techniques were interchanged with MR imaging. For dGEMRIC, a double routine dose of Gd-DTPA2− (0.2 mM/kg) was administered intravenously. For iGEMRIC, 2.5 and 1.25 mmol/l saline-diluted Gd-DTPA2− solutions were separately injected into the right and left knee joints, respectively, prior to MR imaging. Color-coded T1 maps of 20 femoral condyles were obtained from the dGEMRIC and iGEMRIC images. The signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and glycosaminoglycan (GAG) delineation of articular cartilage were compared between the dGEMRIC and iGEMRIC techniques. Results: The mean SNR was higher with dGEMRIC than with iGEMRIC, but the difference was not statistically significant (P = 0.174). The mean (±SD) CNR was higher with iGEMRIC (−11.6±3.4) than with dGEMRIC (−16.7±4.0; P = 0.000), although the absolute value of the CNR was higher with dGEMRIC. The layering and gradient distribution of GAG were more clearly visualized on the iGEMRIC images. The mean scores of GAG delineation with dGEMRIC and iGEMRIC were 0.7±0.6 and 2.2±1.7, respectively. The iGEMRIC method better visualized GAG distribution (P = 0.001). Conclusion: Although the SNR did not differ significantly between the iGEMRIC and dGEMRIC techniques, the color-coded T1 map produced with iGEMRIC allowed better cartilage evaluation. Thus, iGEMRIC exhibits the useful features of both MR arthrography and dGEMRIC, and provides a color-coded T1 map that is useful for diagnosing early articular cartilage damage.

A probable case of oral bisphosphonate-associated osteonecrosis of the jaw and recovery with parathyroid hormone treatment.

INTRODUCTION Bisphosphonates are effective for treating osteoporosis, Pagets disease of bone, and malignancy-associated bone diseases. Bisphosphonate-associated osteonecrosis of the jaw (ONJ) is a rare but serious adverse effect of bisphosphonate therapy. Due to inhibitory actions on bone turnover, bisphosphonate therapy may result in the accumulation of microdamage. CASE SUMMARY A 74-year-old Korean woman (height, 150 cm; weight, 51 kg) was referred to the Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, South Korea, for evaluation of pain and persistent abnormal exposure of jaw bone after extraction of teeth. She had been receiving weekly oral alendronate treatment for osteoporosis for ~5 years. The patient had the clinical features of bisphosphonate-associated osteonecrosis of the mandible, which was precipitated by teeth extraction ~14 months prior to the outpatient referral visit. At her clinical baseline visit, serum hormone concentrations and bone turnover markers were as follows: thyroid-stimulating hormone, 0.88 μIU/mL (reference range, 0.25-5.00 μIU/mL); 25-hydroxyvitamin D3, 20.9 (9.0-37.6) ng/mL; parathyroid hormone (PTH), 57 (11-62) pg/mL; serum osteocalcin, 8.7 (12.9-55.9) ng/mL; and urine N-telopeptide 21 (26-124) nM/mM creatinine. She had multiple systemic risk factors for ONJ, including older age, type 2 diabetes mellitus, and long duration of bisphosphonate therapy. There was no mandibular lesion improvement despite repeated surgical procedures performed within a 14-month period. Bisphosphonate therapy was discontinued and PTH therapy was started. After 2 months, exposed oral mucosa had healed. After 4 months of treatment, the pain had completely subsided, and after 6 months the patients eating and drinking habits returned. The serum concentration of osteocalcin, a bone formation marker, which was initially suppressed (8.7 ng/mL), increased 174% (15.1 ng/mL) from baseline after 6 months of treatment with PTH. CONCLUSIONS Here we report a probable case of oral bisphosphonate-associated ONJ featuring suppressed bone turnover. Treatment with the bone formation-stimulating agent PTH was beneficial.

Subacromial Corticosteroid Injection on Poststroke Hemiplegic Shoulder Pain: A Randomized, Triple-Blind, Placebo-Controlled Trial

OBJECTIVE To evaluate the effect of subacromial corticosteroid injection on hemiplegic shoulder pain (HSP). DESIGN Multicenter, randomized, triple-blind, placebo-controlled trial. SETTING Three primary and 1 university-affiliated tertiary-care hospitals. PARTICIPANTS Poststroke HSP patients (N=58) with evidence of rotator cuff disorder. INTERVENTIONS Participants were randomly assigned to receive ultrasound-guided subacromial injection with triamcinolone 40mg (treatment group, n=29), or lidocaine (placebo group, n=29). After a single injection, participants were followed up for 8 weeks. MAIN OUTCOME MEASURES Visual analog scale (VAS) of the average shoulder pain level at day and night (VAS-day/night, the primary outcome measures), Modified Barthel Index, Shoulder Disability Questionnaire (SDQ), and angles of shoulder active range of motion (flexion, abduction, external rotation, and internal rotation) at pretreatment and weeks 2, 4, and 8 posttreatment. RESULTS There was no significant difference between the 2 groups in the main outcome measures at pretreatment. Compared with the placebo group, VAS-day/night, SDQ, flexion, external rotation, and internal rotation showed significant improvement in the treatment group. CONCLUSIONS To our knowledge, this is the first randomized, placebo-controlled study to assess the efficacy of subacromial injection in HSP patients with evidence of rotator cuff disorder. Subacromial corticosteroid injection showed improvement in pain, disability, and active range of motion, and the duration of its efficacy continued up to 8 weeks.

Primary pulmonary malignant fibrous histiocytoma mimics pulmonary artery aneurysm with partial thrombosis: various radiologic evaluations

Primary pulmonary malignant fibrous histiocytoma (MFH) is very rare, so only a few imaging features have been reported. We report one case of rapidly growing primary pulmonary MFH mimicking a partially thrombosed pulmonary artery aneurysm and its radiologic findings, including multidetector row computed tomography (MDCT), conventional angiography, and fluorodeoxyglucose-positron emission tomography CT ([18F] FDG-PET/CT). On multi-phasic MDCT, this mass mimicked a pulmonary artery aneurysm with partial thrombosis. However, pulmonary artery aneurysm was excluded and suggested as a hypervascular parenchymal mass by subsequent conventional angiography. On [18F] FDG-PET/CT, it was a highly metabolic mass, showing a maximal standard uptake value (SUV) 12.1. Although primary pulmonary MFH is very rare and has no specific imaging findings, our experience might be helpful to differentiate a hypervascular pulmonary mass.

Prolotherapy for Refractory Rotator Cuff Disease: Retrospective Case-Control Study of 1-Year Follow-Up

OBJECTIVE To determine the efficacy of prolotherapy for refractory rotator cuff disease. DESIGN Retrospective case-control study. SETTING University-affiliated tertiary care hospital. PARTICIPANTS Patients with nontraumatic refractory rotator cuff disease (N=151) who were unresponsive to 3 months of aggressive conservative treatment. Of the patients, 63 received prolotherapies with 16.5% dextrose 10-ml solution (treatment group), and 63 continued conservative treatment (control group). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Visual analog scale (VAS) score of the average shoulder pain level for the past 1 week, Shoulder Pain and Disability Index (SPADI) score, isometric strength of the shoulder abductor, active range of motion (AROM) of the shoulder, maximal tear size on ultrasonography, and number of analgesic ingestions per day. RESULTS Over 1-year follow-up, 57 patients in the treatment group and 53 in the control group were analyzed. There was no significant difference between the 2 groups in age, sex, shoulder dominance, duration of symptoms, and ultrasonographic findings at pretreatment. The average number of injections in the treatment group is 4.8±1.3. Compared with the control group, VAS score, SPADI score, isometric strength of shoulder abductor, and shoulder AROM of flexion, abduction, and external rotation showed significant improvement in the treatment group. There were no adverse events. CONCLUSIONS To our knowledge, this is the first study to assess the efficacy of prolotherapy in rotator cuff disease. Prolotherapy showed improvement in pain, disability, isometric strength, and shoulder AROM in patients with refractory chronic rotator cuff disease. The results suggest positive outcomes, but one should still take caution in directly interpreting it as an effective treatment option, considering the limitations of this nonrandomized retrospective study. To show the efficacy of prolotherapy, further studies on prospective randomized controlled trials will be required.