William G. Totty

Ultrasonographic evaluation of the rotator cuff and biceps tendon.

Ultrasonography of the rotator cuff and biceps tendon was investigated in 106 patients who had been referred for arthrography of the shoulder. Both the sensitivity and the specificity of ultrasound in detecting a tear of the rotator cuff were 91 per cent. The predictive value of a negative sonogram was 95 per cent and the predictive value of a positive sonogram was 84 per cent. Ultrasonography proved to be superior to arthrography in the examination of the normal and abnormal biceps tendon. Sonographically detectable effusions from the tendon sheath of the biceps were present in 19 per cent of this population of patients. This finding was statistically highly associated (90 per cent) with rotator cuff tears and other soft-tissue abnormalities of the shoulder. Based on these results, it appears that ultrasonography can be used as the initial imaging test for many patients with suspected abnormalities of the rotator cuff or biceps tendon.

Magnetic resonance imaging using gadolinium labeled monoclonal antibody

Gadolinium was attached to antibodies and tested in vitro and in vivo for its effect on proton relaxation enhancement. Using the cyclic anhydride method, diethylenetriaminepentaacetic acid (DTPA) was attached to albumin, IgG and anti-CEA monoclonal antibody. Gadolinium (Gd) was then chelated to the protein complexes forming protein-DTPA-Gd complex. With this technique approximately 9 atoms of Gd could be attached to each albumin molecule, 4 to each IgG molecule and 1.5 to each monoclonal antibody molecule. The minimal in vitro concentration of Gd in the form of IgG-DTPA-Gd necessary to produce proton relaxation enhancement at 0.35 tesla was 10(-1) mM. An in vivo experiment using anticarcinoembryonic antigen (CEA) monoclonal antibody-DTPA-Gd in hamsters implanted with human colon carcinoma resulted in a tumor concentration of Gd of less than 10(-4) mM. No enhancement of the tumors was detected at that concentration. For monoclonal antibodies to function as selective MR contrast agents, substantial advances in technology must occur.

Thrombolytic therapy for acute arterial occlusion

To evaluate the role of selective intra-arterial low-dose thrombolytic therapy (SILDT) as an alternative to the surgical management of acute arterial occlusion, the hospital records of 40 patients who underwent 43 SILDT treatments with either streptokinase (36) or urokinase (7) between December 1979 and March 1984 were reviewed. Twenty-eight patients underwent 30 treatments (group 1) for native arterial occlusion and 12 patients underwent 13 treatments (group 2) for prosthetic or autogenous graft occlusions. Therapy was deemed successful if subsequent surgical therapy was obviated. In group 1, SILDT was successful in 13 of 28 (45%) patients with 12 of 25 lower extremity occlusions and one of three upper extremity occlusions. Successful lysis in the native artery occlusion group fell into three categories: five patients were successfully treated for arterial thrombosis complicating percutaneous transluminal angioplasty (PTA); four patients required PTA after complete lysis revealed an underlying arterial stenosis; and only three required no further therapy after SILDT. SILDT failed in all three patients with the aortoiliac occlusions. Eleven patients with femoral artery occlusions and unsuccessful SILDT required six bypass procedures, three amputations, one embolectomy, and one PTA. In group 2 only 3 of 14 treatments (21%) were successful. Bypass revision was not possible in 11 patients and all required amputation. Systemic fibrinolysis was seen in 20 (59%) of 34 patients with available data. Neither fibrinogen levels nor fibrin degradation products predicted the occurrence of complications. Minor complications occurred in 18 of 43 (43%) treatments; small hematomas at the catheter entry site were most common. Minor complications occurred in 20 of 43 treatments (44%) and included severe local hemorrhage (four), distant bleeding (three), pulmonary embolism (four), myocardial infarction (three), unmasking of an aortoduodenal fistula (one), and clot migration requiring emergency thrombectomy (four). SILDT is most effective in acute arterial thrombosis complicating arteriography or percutaneous angioplasty. It may play a role in the patient in whom thrombolysis can reveal an underlying stenosis amenable to percutaneous angioplasty. This experience shows SILDT to be of limited value in the management of prosthetic autogenous graft occlusions. Finally, thrombolytic therapy is associated with significant morbidity and mortality rates and requires cautious monitoring to detect arterial thrombus migration, worsening tissue ischemia, venous thromboembolism, intracerebral hemorrhage, and local or systemic bleeding.

Giant vertebral notochordal rest: a lesion distinct from chordoma: discussion of an evolving concept.

A 14-year-old boy with severe back pain for several years is described. Roentgenograms, bone scans, and computed tomographic scans of the spine were normal, but magnetic resonance imaging studies showed a lumbar vertebral body lesion, confined to the bone, with low T1- and high T2-weighted signal intensities. Histologically, the lesion consisted of sheet-like notochordal-type tissue, containing physaliphorous cells but lacking the usual features of chordoma. A diagnosis of giant notochordal rest was made. A review of prior possible examples of this recently described and controversial entity is made with a discussion of its embryologic foundations and distinction from chordoma.

Solitary skeletal hemangioma of the extremities.

Abstract Objective. To report the clinicopathologic features of solitary skeletal hemangioma of the extremities and to review previous cases in the English language medical literature. Patients. In addition to five of our own cases, 34 literature cases with substantial and 75 with partial clinicopathologic information were found. Results. Our patients, three men and two women, ranged in age from 37 to 83 years (mean 65.6 years). The lesion was an incidental radiologic finding in two patients, while three were symptomatic. In no case was a correct preoperative radiologic diagnosis made, a malignant process being considered as a possibility in all. The hemangiomas were medullary; two involved a metacarpal, two the fibula, and one the humerus. In contrast, previously reported patients were younger (mean age 32 years), predominantly female (60%), and symptomatic in over 90% of cases. The lesion is rare in those younger than age 10 years or older than age 60 years. As in our patients, the long bones are most frequently involved (75%), with the diaphysis or metadiaphysis, as in four of our patients, the most common locations. Although 20% of cases occur in the hands or feet, metacarpal involvement is rare. Medullary origin, as in all of our cases, is most frequent, but 45% of cases are either periosteal (33%) or intracortical (12%). In the literature, cavernous hemangioma is the most frequent type. Three of our hemangiomas were cavernous, one capillary, and one venous, the latter being rarely reported in extremity bones. Conclusions. Due to the diversity of radiologic patterns produced by skeletal hemangioma, a correct preoperative diagnosis is rarely made. Almost all patients do well, even those with less than complete removal of the lesion; local recurrence is rare. All of our patients were well following either therapeutic or simple diagnostic procedures. Due to the destructive nature of some biopsy procedures, the histologic diagnosis of hemangioma may at times also be problematic.

Arthrographic evaluation of the carpal triangular fibrocartilage complex

One hundred sixty-two patients had analyses for correlation of triangular fibrocartilage abnormalities (TFCC), with duration and location of pain and other possible associated radiographic, scintigraphic, and arthrographic abnormalities. Results indicated that TFCC perforations did not correlate with any pain complex or other associated radiographic, arthrographic, or scintigraphic abnormality. No association with carpal instability or with ulnar variance could be identified. No definition between perforations that were posttraumatic and those that were the results of a degenerative process could be made. Several small defects on both the proximal and distal surfaces of the TFCC were identified. They do not appear to have been reported previously in the literature. Their significance is discussed.

Posteroanterior wrist radiography: Importance of arm positioning

Proper interpretation of wrist radiography requires a standardized radiographic technique. We obtained posteroanterior (PA) radiographs of the wrist in nine patients in three different arm positions to study the effect of arm position on ulnar styloid process orientation. An appearance simulating a normal anteroposterior (AP) wrist radiograph was present in six of nine PA radiographs when the arm was positioned next to the trunk, and the elbow was flexed to a 90% angle. The orientation of the ulnar styloid was not helpful in differentiating either pronated from supinated wrist positions or AP from PA projections. We concluded that radiographic screening of the carpus should be performed with standardized wrist positioning and nomenclature as described in modern radiographic technological texts. Supplemental projections should be exposed and interpreted with an understanding of the position of the arm and the direction of the incident radiographic beam at the time of examination.

Skeletal Fluorosis From Instant Tea

Introduction: Skeletal fluorosis (SF) can result from prolonged consumption of well water with >4 ppm fluoride ion (F−; i.e., >4 mg/liter). Black and green teas can contain significant amounts of F−. In 2005, SF caused by drinking 1–2 gallons of double‐strength instant tea daily throughout adult life was reported in a 52‐yr‐old woman.

Relative value of computed tomography and ultrasonography in the assessment of renal angiomyolipoma.

Imaging studies on six patients with known angiomyolipomas were reviewed to determine the contribution of each imaging modality to the preoperative diagnosis. A spectrum of clinical presentations from asymptomatic patients with tuberous sclerosis to acutely ill patients with flank pain and hypotension was included. Findings varied from multiple, small, bilateral intrarenal masses to single larger masses with extrarenal components. Computed tomography (CT) identified fat containing masses in all cases. Ultrasound showed hyperechoic masses in all four cases in which it was utilized. In addition, CT allowed diagnosis of associated hematomas and additional angiornyolipomas not seen on other studies. Ultrasound provided a noninvasive follow-up method without the use of ionizing radiation.

Juvenile Paget's Disease: The Second Reported, Oldest Patient Is Homozygous for the TNFRSF11B “Balkan” Mutation (966_969delTGACinsCTT), Which Elevates Circulating Immunoreactive Osteoprotegerin Levels†‡§¶

The oldest person (60 yr) with juvenile Pagets disease is homozygous for the TNFRSF11B mutation 966_969delTGACinsCTT. Elevated circulating levels of immunoreactive OPG and soluble RANKL accompany this genetic defect that truncates the OPG monomer, preventing formation of OPG homodimers.