Robert H. Freiberger

Double-contrast Arthrography of the Knee: Its Value In The Management Of Two Hundred And Twenty-five Knee Derangements

1. Arthrography of the knee is a valuable diagnostic procedure. In 225 consecutive knees examined and operated on by the same surgeon, the preoperative arthrograms, all performed and interpreted by the same radiologist, demonstrated meniscal tears correctly in 97.5 per cent of the 200 knees with such lesions, giving an accuracy of 99.7 per cent in the 143 lesions of the medial meniscus and of 93 per cent in the fifty-seven lesions of the lateral meniscus. Five tears found at operation were not demonstrated by arthrography, four in the lateral and one in the medial meniscus. In six patients, tears of both menisci, unsuspected on the basis of the clinical examination, were demonstrated correctly on the arthrograms. In no instance did an arthrogram indicate a tear in a meniscus which was not corroborated at surgery. In twenty-five patients with lesions other than meniscal tears, the arthrograms were helpful but not diagnostic for all types of lesions. 2. Prolonged observation and procrastination in the treatment of patients with symptomatic knees were avoided. The surgeon and patient were assured of a correct preoperative diagnosis, especially when the clinical signs were not specific and the symptoms were intermittent and not disabling. 3. Unnecessary surgery was reduced. 4. Arthrography revealed residual portions of the meniscus left after previous meniscectomy in eight patients, one of the retained fragments being itself torn. Reoperation resulted in cure in all eight patients. Osteochondral fractures were also demonstrated as well as loose fragments more than eight millimeters in diameter. 5. In this series, one-half of the thirty-four tears of the anterior cruciate ligament were demonstrated by arthrography. We are still developing the technique to demonstrate the cruciate ligaments on arthrograms. 6. Four patients with no anteroposterior instability were shown to have anterior cruciate tears by arthrography. 7. There were no complications of arthrography in this series. All patients returned to work immediately after the procedure.

ACQUIRED ABSENCE OF THE ODONTOID PROCESS: A CASE REPORT.

A case is presented of acquired absence of the odontoid process in a child, two and one-half years old, occurring most probably as the result of an ununited fracture. The roentgenographic findings were similar to those reported with congenital absence of the odontoid process.

Arthrography for Complications of Total Hip Replacement: A Review Of Thirty-one Arthrograms

In patients with persistent pain after total replacement of the hip, arthrography during aspiration has been found to be useful for verification of the proper intracapsular placement of the needle and for the diagnosis of loosening of the prosthesis. The presence of soft-tissue abscesses or sinuses can also be demonstrated on occasion before the clinical picture of infection is definitely established, as well as other rarer pathological entities. The technique is most useful when radiolucent acrylic cement has been used, but it is also helpful for the diagnosis of complications when radiopaque acrylic cement has been used.

Untreated congenital hip dysplasia in the Navajo.

Congenital hip dysplasia without dislocation was identified in 18 Navajo Indian children. Treatment had been declined and the children presented a unique opportunity to observe the natural course of hip dysplasia. In a follow-up period of three to 19 years (average, 11.2 years), none of the dysplastic hips were observed to progress to dislocation. In 15 of the children with dysplastic hips, the condition became roentgenographically normal in the course of normal growth and development. The other three children continued to show roentgenographic signs of hip dysplasia.

Slipped Femoral Capital Epiphysis as a Sequela to Childhood Irradiation for Malignant Tumors

Five cases of slipped femoral capital epiphysis were noted in children with prior irradiation for malignancy whose femoral head and neck had been included in the radiation portal. Three of the 5 were patients who had lymphoma. As a result of increasing survival rates for these types of patients, this previously unrecognized radiation-related growth disturbance may be more likely to be seen in the future.

Radiologic Evaluation of Painful Joint Prostheses

The most important method of evaluation of painful total joint prostheses is review of sequential radiographs. Because clinical failure from loosening occurs late, abnormalities of alignment, the cement-bone or cement-metal interface, the bony contour, or the integrity of the prosthetic components will be found in the vast majority of cases of clinical failure. In cases in which plain radiographs are normal or equivocal, radionuclide bone scanning with Tc-99m diphosphonate agents are useful. A diffuse increase in vascularity and in uptake of radionuclide is present in infection, while a normal scan suggests that infection or loosening is unlikely. Positive arthrograms are helpful in confirming loosening and in demonstrating abscess cavities and sinus tracts, but negative arthrograms have little significance. Asymptomatic patients with radiographic evidence of loosening should be followed with sequential roentgenograms for signs of progressive bone destruction.

Peptic Ulcers in Rheumatoid Patients Receiving Corticosteroid Therapy

This paper represents a portion of a clinical and experimental study (13) to determine the frequency with which peptic ulcers occur in patients with rheumatoid arthritis under treatment with various corticosteroid drugs and to investigate the effect of corticosteroids on gastric secretions. The present report is concerned only with the incidence of ulcers, their distribution, location, and roentgen appearance. Shortly after the introduction of corticosteroids for clinical use in 1950, reports began to appear on the increased occurrence of peptic ulcers in patients treated by these substances. Howell and Ragen (6) reported 18 ulcers in 68 patients receiving cortisone for five to thirty months. Other investigators placed the incidence anywhere from 5 per cent to as high as 37 per cent (7–10). Henderson (4) found that only 5.3 per cent of 1,440 patients treated with cortisone had ulcers. In another series, of 446 cases analyzed by the American Rheumatism Association (5), the figure was 6.6 per cent, which is...

Eosinophilic granuloma of the spine without vertebra plana. A report of two unusual cases.

Roentgenologists have been trained to think of eosinophilic granuloma of the spine as a disease presenting with vertebra plana (Fig. 1). Following Calves first description of vertebra plana (1) and the initial descriptions of eosinophilic granuloma of bone as a distinct pathological entity (2, 3), subsequent reports indicated that most cases of vertebra plana were due to this tumor (4–7). Almost no attention has been given to other appearances of eosinophilic granuloma of the spine. The authors know of only two reported cases of this tumor of the spine without vertebra plana (8). Other reports have described an “atrophy” or “rarification” of the pedicles in association with vertebra plana (9–10). We have recently encountered two cases of eosinophilic granuloma of the spine without vertebra plana. Both cases presented as lytic and slightly expansile lesions involving the posterior aspects of the vertebral bodies, the neural arches, and the appendages. Case I (Figs. 2–4): N. S., a 21-year-old female, was a...

Vertebral Destruction at Unfused Segments in Late Ankylosing Spondylitis

ESTRUCTIVE changes at vertebral bodies have been described in ankylosing spondylitis. Usually they are seen at a fairly early stage of the disease and are apparently caused by rheumatoid granuloma (1–4, 6, 8). The association of destructive changes at the anterior articular surface of the vertebral bodies in late stages of this disease and at a segment where neither the spinous ligaments are completely ossified nor the apophyseal joints are fused has apparently not been reported. It appears that the vertebral destruction is caused by a pseudarthrosis. Motion of some degree is present and, because of solid fusion of the spine above and below the area of pseudarthrosis, great stress forces are being exerted on the anterior margins of the vertebral bodies, leading to absorption of bone and bone sclerosis. Patient S. S. (CASE I) clearly showed massive vertebral bone absorption, motion on flexion and extension, and open apophyseal joints by quite conventional x–ray methods (Fig. 1). His major complaint had bee...

Severe growth disturbance with osteoid osteoma. A report of two cases involving the femoral neck.

Abstract Two cases of osteoid osteoma of the femoral neck causing unusually severe bone and joint deformities are presented. The lesions existed for eight years by radiological evidence in one case and for seven years by history in the other. Localized hyperemia and muscle contractures over several years during the growth period are believed to cause the growth deformities. Early surgical excision is advised, not only to relieve the pain and prevent the contractures and deformities, but also to guard against the possibility of osteoarthritis later in life.