Milko C. de Jonge

Sport injuries in the paediatric and adolescent patient: a growing problem

With an increasing number of paediatric and adolescent athletes presenting with injuries due to overuse, a greater demand is put on clinicians and radiologists to assess the specific type of injury. Repetitive forces applied to the immature skeleton cause a different type of injury than those seen in adults due to the differences in vulnerability of the musculoskeletal system, especially at the site of the growth cartilage. Intrinsic and extrinsic risk factors all play a role in the development of overuse injuries. MRI plays a key role in imaging overuse injuries due to its high potential for depicting cartilaginous and soft-tissue structures. Sport-specific biomechanics are described, since this knowledge is essential for adequate MRI assessment. An overview of several sport-related injuries is presented, based on anatomical location.

Less Promising Results With Sclerosing Ethoxysclerol Injections for Midportion Achilles Tendinopathy A Retrospective Study

Background Local injections of the sclerosing substance polidocanol (Ethoxysclerol) have shown good clinical results in patients with chronic midportion Achilles tendinopathy. After training by the inventors of the technique, sclerosing Ethoxysclerol injections were applied on a group of patients in our center. Hypothesis Sclerosing Ethoxysclerol injections will yield good results in the majority of patients. Study Design Case series; Level of evidence, 4. Methods In 113 patients (140 tendons) with Achilles tendinopathy, we identified 62 patients (70 tendons) showing neovascularization on color Doppler ultrasound. Fifty-three Achilles tendons (48 patients) were treated with sclerosing Ethoxysclerol injections, with intervals of 6 weeks and a maximum of 5 sessions. Treatment was completed when neovascularization or pain had disappeared, or when there was no positive treatment effect after 3 to 4 sessions. Results Forty-eight patients (20 women and 28 men) with a median age of 45 years, (range, 33-68 years) were treated. Median symptom duration was 23 months (range, 3-300 months). Fifty-three tendons were treated with a median of 3 sessions of Ethoxysclerol injections. Six weeks after the last injection, 35% of patients had no complaints, 9% had minimal symptoms, 42% were the same, and 14% had more complaints. Women were 3.8 times (95% confidence interval: 1.1-13.8) more likely to have unsatisfactory outcome than men. Pain correlated positively with neovessels on ultrasound (P < .01). At 2.7 to 5.1 year follow-up, 53% had received additional (surgical/conservative) treatment; 3 of these patients (7.5%) still had complaints of Achilles tendinopathy. In 6 patients, complaints that were still present 6 weeks after treatment had resolved spontaneously by final follow-up. Conclusion Our study did not confirm the high beneficial value of sclerosing neovascularization in patients with midportion Achilles tendinopathy. Despite the retrospective design of our study, we consider it important to stress that injection of Ethoxysclerol may not be as promising as was thought.

Reliability and responsiveness of the Juvenile Arthritis MRI Scoring (JAMRIS) system for the knee

ObjectivesTo assess the reliability and responsiveness of a new Juvenile Arthritis MRI Scoring (JAMRIS) system for evaluating disease activity of the knee.MethodsTwenty-five juvenile idiopathic arthritis (JIA) patients with clinical knee involvement were studied using open-bore 1-T MRI. MRI features of synovial hypertrophy, bone marrow changes, cartilage lesions and bone erosions were independently scored by five readers using the JAMRIS system. In addition, the JAMRIS system was determined to be a follow-up parameter by two readers to evaluate the response to therapy in 15 consecutive JIA patients.ResultsInter-reader (ICCs 0.86–0.95) and intra-reader reliability (ICCs 0.92–1.00) for the scoring of JAMRIS features was good. Reliability of the actual scores and changes in scores over time was good for all items: ICCs 0.89–1.00, 0.87–1.00, respectively. Concerning therapy response, the mean synovial hypertrophy scores decreased significantly (mean 1.1 point; Pu2009<u20090.001, SRMu2009=u2009−0.65). No change was observed with respect to bone marrow change, cartilage lesion and bone erosion scores.ConclusionsThe JAMRIS proved to be a simple and highly reliable assessment score in the evaluation of JIA disease activity of the knee. The JAMRIS system may serve as an objective and accurate outcome measure in future research and clinical trials.Key Points• MRI is increasingly used to diagnose and assess juvenile idiopathic arthritis.• A simple and reliable scoring method would help monitor progress and research.• The Juvenile Arthritis MRI Scoring (JAMRIS) system provides reliable objective measures.• JAMRIS evaluates synovial hypertrophy, bone marrow changes, cartilage lesions and bone erosions.• The JAMRIS system can detect therapeutic response and should help future research.

Injection Techniques of Platelet-Rich Plasma into and around the Achilles Tendon a Cadaveric Study

Background Platelet-rich plasma (PRP) injections are used to treat (Achilles) tendinopathies. Platelet-rich plasma has been injected at different locations, but the feasibility of PRP injections and the distribution after injection have not been studied. Purpose To evaluate (1) the feasibility of ultrasound-guided PRP injections into the Achilles tendon (AT) and in the area between the paratenon and the AT and (2) the distribution of PRP after injection into the AT and in the area between the paratenon and AT. Study Design Descriptive laboratory study. Methods Fifteen cadaveric lower limbs were injected under ultrasound guidance with Indian blue–dyed PRP. Five injections were placed into the AT at the midportion level; 5 injections were located anterior between the paratenon and AT and 5 posterior between the paratenon and AT. The limbs were anatomically dissected and evaluated for the presence and distribution of PRP. Results All injections into the AT showed PRP infiltration in the AT as well as in the area between the paratenon and AT (median craniocaudal spread, 100 mm; range, 75-110 mm); 1 of 5 limbs showed PRP leakage into the Kager fat pad after AT injection. All anterior and posterior injections showed PRP infiltration in the area between the paratenon and AT (median, 100 mm; range, 75-150 mm). The AT was infiltrated with PRP after 3 of 10 paratenon injections. Conclusion The “AT” and “paratenon” injections under ultrasound guidance proved to be accurate. Injections into the AT showed distribution of PRP into the AT as well as in the area between the paratenon and AT. All injections between the paratenon and AT showed PRP distribution in that area, as well as in the Kager fat pad. Clinical Relevance Different PRP injection techniques were evaluated. This aids in the optimization of PRP injections in the treatment of midportion Achilles tendinopathy.

Soft tissue tumors in adults: ESSR-approved guidelines for diagnostic imaging

Soft tissue sarcomas are rare, but early, accurate diagnosis with subsequent appropriate treatment is crucial for the clinical outcome. The ESSR guidelines are intended to help radiologists in their decision-making and support discussion among clinicians who deal with patients with suspected or proven soft tissue tumors. Potentially malignant lesions recognized by ultrasound should be referred for magnetic resonance imaging (MRI), which also serves as a preoperative local staging modality, with specific technical requirements and mandatory radiological report elements. Radiography may add information about matrix calcification and osseous involvement. Indeterminate lesions, or lesions in which therapy is dependent on histology results, should be biopsied. For biopsy, we strongly recommend referral to a specialist sarcoma center, where an interdisciplinary tumor group, with a specialized pathologist, radiologist, and the surgeon are involved. In sarcoma, a CT scan of the chest is mandatory. Additional staging modalities are entity-specific. There are no evidence-based recommendations for routine follow-up in surgically treated sarcomas. However, we would recommend regular follow-up with intervals dependent on tumor grade, for 10 years after the initial diagnosis.

Bone marrow edema-like signal in the athlete

Sports medicine is one of the most rapidly growing subspecialties in orthopaedics and therefore radiologists will be confronted with it more and more often. With the increased use of MR imaging in evaluating joint and muscle pathology in athletes new challenges emerge. One of these challenges is the role of BME, high-signal intensity on T2-weighted MR images. Some studies find a positive association between BME and clinical complaints, whereas other studies do not. Even more interesting is the finding that BME seems to appear quite often in asymptomatic athletes, although little has been reported in the literature about the MR imaging findings in the asymptomatic knee of the dedicated athlete. As the field of sports medicine expands, radiologists will increasingly deal with the presence of BME in athletes.

Region of interest and pixel-by-pixel analysis of dynamic contrast enhanced magnetic resonance imaging parameters and time-intensity curve shapes : a comparison in chondroid tumors

UNLABELLEDnDynamic contrast enhanced (DCE) MRI is widely acknowledged to be a helpful tool in the diagnosis and differentiation of tumors. In common clinical settings, the dynamic changes described by the time-intensity curves (TICs) are evaluated to find patterns of atypical tissue behavior, i.e., areas characterized by rapid contrast wash-in and wash-out. Despite the ease of this approach, there is no consensus about the specificity of the TIC shapes in discriminating tumor grades. We explore a new way of looking at TICs, where these are not averaged over a selected region of interest (ROI), but rendered pixel-by-pixel. In this way, the characteristic of the tissue is not given as a single TIC classification but as a distribution of the different TIC patterns. We applied this method in a group of patients with chondroid tumors and compared its outcome with the outcome of the standard ROI-based averaged TIC analysis. Furthermore, we focused on the problem of ROI selection in these tumors and how this affects the outcome of the TIC analysis. Finally, we investigated what relationship exists between the standard DCE-MRI parameter maximum enhancement (ME) and the TIC shape.nnnCONCLUSIONSnWe demonstrate that, where the ROI approach fails to show the presence of areas of rapid contrast wash-in and wash-out, the pixel-by-pixel approach reveals the coexistence of a heterogeneous pattern of TIC shapes. Secondly, we point out the differences in the DCE MRI parameters and tumor volume that can result when selecting the tumor based on DCE parameter maps or post-contrast T1-weighted images. Finally, we show that ME maps and TIC shape maps highlight different tissue areas and, therefore, the use of the ME maps is not appropriate for the correct identification of areas of atypical TICs.

Spine and sport.

The spine, in athletes is a relatively frequent origin of problems. Chronic spine problems are much more common compared to acute injuries. Chronic injuries to the spine most often occur in low-contact sports like gymnastics and are most commonly the result of overuse. Acute injuries are more common in high-speed and full contact sports and are traumatic in origin. Injuries to the spinal cord can be devastating but are fortunately very uncommon. Although imaging of the spine appears to be straightforward, any radiologist will acknowledge that the optimal imaging strategy is often unclear due to several reasons. For the cervical spine much has improved since the NEXUS and CCR studies appeared in which clear rules were defined when to image the C-spine in acute trauma situations. For the thoracic and lumbar spines such rules are not defined. Although conventional imaging has long been the primary imaging modality of choice there is ample evidence that this should be abandoned in favor of multidetector CT for the C-spine. This is reflected in the ACR criteria in which conventional imaging of tile C-spine in trauma is rated as the least appropriate imaging method. However, this is not true in children and adolescents although a strict age criterion is not defined. It is also not true for injuries to the thoracic and lumbar spine in which conventional imaging still plays a large role as primary imaging modality followed by evaluation by CT in trauma situations. The role for MRI in acute situations is increasing especially with the increasing use of the TLICS system to classify injuries of the thoracic and lumbar spine in which the evaluation of the integrity of the posterior ligamentous structures is included. For the evaluation of chronic complaints, the roles of CT and MRI are basically reversed in which MRI will become the prime imaging modality of choice after conventional imaging after which CT can be reserved for a selected patient group. The merit of the different imaging modalities will be discussed together with a spectrum of acute and chronic injuries often encountered in the spine in athletes.

Comparison of Postinjection Protocols After Intratendinous Achilles Platelet-Rich Plasma Injections: A Cadaveric Study

The purpose of the present investigation was to evaluate the distribution of intratendinous injected platelet-rich plasma (PRP) after 15 minutes of prone resting versus immediate manipulation simulating weightbearing. Ten cadaveric lower limbs were injected under ultrasound guidance with PRP dyed with India blue ink. The dyed PRP was injected into the mid-portion of the Achilles tendon, after which 5 specimens were placed in the prone position for 15 minutes (simulating rest) and the remaining 5 specimens were manipulated through 100 cycles of ankle dorsiflexion and plantarflexion (simulating walking). Thereafter, the specimens were dissected, and the distribution of the India blue dye was ascertained. In the simulated rest group, every specimen showed dyed PRP in the Achilles tendon and in the space between the paratenon and tendon. The median craniocaudal spread of the PRP was 140 (range 125 to 190) mm. In 4 of the simulated rest tendons (80%), the distribution of PRP extended across the entire transverse plane width of the tendon. In the simulated motion group, every specimen showed dyed PRP extending across the entire transverse plane width of the tendon and in the space between the paratenon and tendon. The median craniocaudal spread was 135 (range 115 to 117) mm. No statistically significant difference was found in the amount of craniocaudal spread between the simulated motion and rest groups. In conclusion, it does not appear to matter whether the ankle has been moved through its range of motion or maintained stationary during the first 15 minutes after PRP injection into the mid-portion of the Achilles tendon. The precise meaning of this information in the clinical realm remains to be discerned.

Complete Avulsion of the Pectoralis Major Tendon: a Case Report

Rupture of the pectoralis major muscle is a rare injury, usually occurring during sports activities or after direct trauma. This article describes the clinical presentation, diagnostic tools and treatment of a patient with a complete avulsion of the pectoralis major tendon.