Tudor H. Hughes

Pigmented villonodular synovitis: MRI characteristics

The magnetic resonance imaging (MRI) scans of 26 patients with histopathologically proven pigmented villonodular synovitis (PVNS), involving joints but excluding tendon sheaths, were reviewed retrospectively. The purpose of this study is to define the spectrum and frequency of MRI characteristics for PVNS using conventional spin echo (in two cases before and after intravenous administration of gadopentate dimeglumine) and also gradient echo techniques. A cystic variety is presented, the MRI appearances of which have not been found in a review of the literature.

Inflammatory Characteristics on Ultrasound Predict Poorer Longterm Response to Intraarticular Corticosteroid Injections in Knee Osteoarthritis

Objective. To assess whether inflammation on ultrasound is predictive of clinical response to intraarticular (IA) corticosteroid injections in patients with knee osteoarthritis (OA). Methods. Patients with symptomatic knee OA were randomized to receive either an IA injection of 40 mg triamcinolone acetonide in the treatment group or 1 cc 0.9% saline in the placebo group. Clinical response was assessed by changes in baseline Western Ontario and McMaster Universities (WOMAC) index scores and physician global assessment at 4 and 12 weeks. Ultrasounds were performed at each visit. Patients and assessors were blinded to treatment status. Results. Seventy-nine patients were enrolled into the study. Four-week data were available for 67 patients in the primary analysis comparing change in WOMAC pain score from baseline to 4 weeks. There was almost no change in the WOMAC pain subscale score from baseline to 4 weeks in the control group, but there was a significant improvement in WOMAC pain subscale score from 10.8 (SD ± 3.2) at baseline to 8.75 (SD ± 4.0) at 4 weeks in the treatment group (adjusted p = 0.001). Of the 34 patients in the treatment group; 16 (47%) had inflammatory disease and 18 (53%) had noninflammatory disease as determined by ultrasound. There was no difference in the change in WOMAC pain score between the inflammatory and noninflammatory patients in the treatment group at 4 weeks. There was a statistically significant greater improvement in pain subscale scores among noninflammatory patients than among inflammatory patients at 12 weeks. Conclusion. Intraarticular corticosteroid injections are an effective short-term treatment for symptomatic knee OA compared to placebo. Patients with noninflammatory characteristics on ultrasound had a more prolonged benefit from IA corticosteroids compared to inflammatory patients.

Magnetic resonance imaging of the hip

Standard magnetic resonance imaging (MRI) as well as MR arthrography (MRA) have been important diagnostic tools to assess for a spectrum of clinical presentations related to the hip. MRA has allowed the radiologist to closely examine intracapsular structures such as the acetabular labrum. In this article, we provide a general review of soft tissue and osseous anatomy of hips, especially focusing on the MR appearances of the acetabular labrum and the osseous morphology of the greater trochanter and ischial tuberosity with their muscle and tendon attachments. In addition, current topics in recent literature will be discussed such as femoroacetabular impingement (FAI) and rotator cuff tears of the hip. J. Magn. Reson. Imaging 2008.

Footprint of the Lateral Ligament Complex of the Ankle

Background: We describe the topographic anatomy of the lateral ligament complex of the ankle using 3-dimensional (3D) computed tomography (CT) imaging. Methods: Dissection of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) was performed on 8 unpaired fresh-frozen cadaver feet. Ligaments were sharply dissected from bone, and the footprint was outlined with radio-opaque paint. The specimen underwent a 0.625-mm slice CT scan of the ankle with 3D reconstructions. Software was used to determine the surface area of the ligament footprint as well as measure the distance from the peroneal tubercle to the center of the CFL footprint. Data are presented as mean ± standard error. Results: Six specimens had a bifid ATFL. Seven ankles had a bifid ATFL footprint on the talus. All specimens had intact CFL fibers. The intact superior and inferior limbs of the ATFL measured 19.7 ± 1.2 mm and 16.7 ± 1.1 mm. The CFL measured 24.8 ± 2.4 mm. The area of the footprints of the superior ATFL and inferior ATFL on the talus measured 1.5 ± 0.26 cm2 and 0.90 ± 0.07 cm2. The CFL and ATFL origins on the fibula were continuous and measured 3.48 ± 0.39 cm2. The CFL insertion on the calcaneus measured 2.68 ± 0.20 cm2. The CFL was found 27.1 ± 1.0 mm posterior and superior from the peroneal tubercle. Conclusions: In presumably uninjured specimens, both the ATFL and its footprint on the talus were bifid. The CFL and ATFL origins have a single confluent footprint on the anterior border of the distal fibula. The CFL footprint on the calcaneus is almost 3 cm posterior and superior to the peroneal tubercle. Clinical Relevance: This study may assist surgeons in anatomically reconstructing the lateral ligament complex of the ankle.

Vascular remodeling underlies rebleeding in hemophilic arthropathy.

Hemophilic arthropathy is a debilitating condition that can develop as a consequence of frequent joint bleeding despite adequate clotting factor replacement. The mechanisms leading to repeated spontaneous bleeding are unknown. We investigated synovial, vascular, stromal, and cartilage changes in response to a single induced hemarthrosis in the FVIII‐deficient mouse. We found soft‐tissue hyperproliferation with marked induction of neoangiogenesis and evolving abnormal vascular architecture. While soft‐tissue changes were rapidly reversible, abnormal vascularity persisted for months and, surprisingly, was also seen in uninjured joints. Vascular changes in FVIII‐deficient mice involved pronounced remodeling with expression of α‐Smooth Muscle Actin (SMA), Endoglin (CD105), and vascular endothelial growth factor, as well as alterations of joint perfusion as determined by in vivo imaging. Vascular architecture changes and pronounced expression of α‐SMA appeared unique to hemophilia, as these were not found in joint tissue obtained from mouse models of rheumatoid arthritis and osteoarthritis and from patients with the same conditions. Evidence that vascular changes in hemophilia were significantly associated with bleeding and joint deterioration was obtained prospectively by dynamic in vivo imaging with musculoskeletal ultrasound and power Doppler of 156 joints (elbows, knees, and ankles) in a cohort of 26 patients with hemophilia at baseline and during painful episodes. These observations support the hypothesis that vascular remodeling contributes significantly to bleed propagation and development of hemophilic arthropathy. Based on these findings, the development of molecular targets for angiogenesis inhibition may be considered in this disease. Am. J. Hematol. 90:1027–1035, 2015.

Melorheostosis with an ossified soft tissue mass: MR features.

A previously healthy 45-year-old man presented with a painful, enlarging mass along the medial aspect of the left knee associated with dysesthesia in the distribution of the infrapatellar branch of the saphenous nerve. There was no history of trauma or constitutional symptoms such as fever, anorexia, or weight loss. Two years previously, he had experienced dysesthesia in the left lower extremity, describing this as nondermatomal in distribution in a stocking-like pattern. Physical examination at that time had not revealed a soft tissue mass about the knee. On physical examination, a palpable mass in the medial aspect of the left knee extended for approximately 15-20 cm in a cephalocauded orientation. The mass was tender to palpation and was characterized as hard, nodular, and mobile. The overlying skin and soft tissues otherwise were unremarkable. There was normal motion of the knee; However, knee pain also suggested the possibility of a medial meniscal tear. Laboratory values were normal. Radiographs of the left knee demonstrated multiple amorphous densities posteromedially within the soft tissues superior to the femorotibial joint. In addition, there was a 1-cm round sclerotic focus in the articular

Hypertrophy of the anterior arch of the atlas associated with congenital nonunion of the posterior arch: a retrospective case-control study

BACKGROUND CONTEXT Nonunion of the posterior arch of the atlas is an uncommon but normal developmental variant. It is usually asymptomatic in the patient but may be associated with greater incidence of fracture because of increased stress on the anterior arch. PURPOSE We sought to determine whether anterior arch hypertrophy is present in cases of congenital nonunion of the posterior arch of the atlas. STUDY DESIGN/SETTING A retrospective analysis of 1 year (February 2005-January 2006) of computed tomography cervical spine studies requested by the University of California San Diego Medical Center Trauma Department was undertaken. PATIENT SAMPLE All patients matching the search criteria (see Study design) were included. OUTCOME MEASURES Area density product, defined as the midline cross-sectional area of the anterior arch on sagittal reformat multiplied by the average areal radiodensity in Hounsfield units (HU) as measured by two raters, was calculated for cases and controls. METHODS Cases of posterior arch nonunion were identified and matched to controls. The significance of differences in area density product between cases and controls were established by the Student t test. Interrater correlation was calculated. RESULTS Posterior arch nonunion was identified in 26 individuals (3.1% of 839 studies reviewed). Compared with age- and sex-matched controls, a 21% increase in area density product of the midline anterior arch was observed in posterior arch nonunion cases (773 HU-cm2 in cases vs. 637 HU-cm2 in controls; p<.001). This increase was attributable to a 21% increase in cross-sectional area (1.05 cm2 in cases vs. 0.87 cm2 in controls; p<.002). In contrast, there was no significant difference with regard to increased average radiodensity. CONCLUSIONS It has long been subjectively recognized but not objectively quantified, until the present study, that the anterior arch of the atlas is hypertrophied in cases of posterior arch nonunion. Anterior arch hypertrophy may represent an adaptive response to chronically elevated mechanical stress and loss of hoop strength in cases of posterior nonunion.

Efficacy and safety of point-of-care ultrasound-guided intra-articular corticosteroid joint injections in patients with haemophilic arthropathy.

Intra‐articular corticosteroid injections are standard of care for managing joint pain secondary to osteoarthritis or rheumatoid arthritis but are rarely used in haemophilic arthropathy. We have introduced and evaluated the efficacy and safety of ultrasound‐guided corticosteroid injections for pain relief in patients with haemophilic arthropathy.

Imaging of the rotator cuff.

The imaging evaluation of the rotator cuff augments the clinical evaluation. Radiography, computed tomography, and magnetic resonance imaging all have various roles in the assessment of the rotator cuff, which can be combined with arthrography for added detail. Furthermore, ultrasound is a very useful technique that provides functional information that is not offered by simple anatomic imaging.

Computed tomography (CT) of fractures of the ankle and foot: correlating fracture patterns with the presence of tenosynovial fat: Tenosynovial fat in ankle and foot fractures.

PURPOSE To correlate ankle and foot fracture patterns with the presence of tenosynovial fat on computed tomography (CT). MATERIALS AND METHODS In this retrospective, cross-sectional, observation study, two blinded musculoskeletal radiologists independently reviewed 89 CT scans of patients with ankle or foot fractures and recorded the presence of fat about Henrys knot, tibialis posterior tendon, and peroneus longus tendon. RESULTS The agreement between the two readers ranged from excellent to substantial. Sixteen to 23 percent of fractures were associated with tenosynovial fat. CONCLUSIONS The finding of tenosynovial fat following ankle or foot trauma warrants a closer search for a fracture.