Assessment of magnetic resonance imaging criteria for the diagnosis of cavernous sinus invasion by pituitary tumors.

Cavernous sinus invasion (CSI) by pituitary tumors is associated with subtotal resection and persistent endocrinopathy. The Knosp classification is a magnetic resonance imaging (MRI) tool used to define CSI in the 2017 World Health Organization Classification. However, alternative criteria may have superior diagnostic performance. This study aimed to assess the diagnostic performance of four MRI criteria, using a combination of endoscopy and day 1 MRI as the reference standard for CSI. A cross-sectional study was conducted including patients treated with endoscopic endonasal transsphenoidal surgery for pituitary macroadenomas, recruited from a tertiary pituitary multidisciplinary center in Sydney, Australia between September 2013, and February 2021. The diagnostic performances of four MRI criteria were assessed: the Knosp criteria, percentage encasement of the internal carotid (PEICA), venous compartment obliteration (VCO), and the Fernandez-Miranda classification. Reference CSI was defined using a combination of intraoperative endoscopy and day 1 MRI. A total of 210 cavernous sinuses (105 patients), were analyzed, (51.7 ±â€¯16.3yrs, 43% female), of which 18% had CSI. CSI was best diagnosed by Knosp ≥ 2 (63% sensitivity and 89% specificity), PEICA ≥ 28% (84% sensitivity and 77% specificity) and VCO of ≥ 3 compartments (65% sensitivity and 89% specificity). CSI was unlikely if any of the following signs were present: Knosp < 1, PEICA < 28%, preservation of the medial or superior compartments or sparing of the superior Fernandez-Miranda compartment (negative predictive value 95%, 95%, 94%, 91% and 92% respectively). In conclusion, alternatives to the Knops criteria including PEICA and VCO can aid CSI diagnosis.

Staging 18F-FDG PET/CT influences the treatment plan in melanoma patients with satellite or in-transit metastases.

Whole-body positron emission tomography/computed tomography (PET/CT) and brain magnetic resonance imaging (MRI) are commonly used to stage patients with palpable lymph node metastases from melanoma, but their role in patients with satellite and/or in-transit metastasis (S&ITM) is unclear. The aim of this study was to establish the diagnostic value of PET/CT and brain MRI in these patients, and to assess their influence on subsequent management decisions. In this prospective study, 25 melanoma patients with a first presentation of S&ITM who had no clinical evidence of palpable nodal or distant metastasis underwent whole-body F-FDG PET/CT and brain MRI after a tentative pre-scan treatment plan had been made. Sensitivity and specificity of imaging were determined by pathological confirmation, clinical outcome and repeat PET/CT and MRI at 6 months. PET/CT led to a modification of the initial treatment plan in four patients (16%). All four were upstaged (AJCC stage eighth edition). PET/CT was false-positive in one patient, who had a Schwannoma in his trapezius muscle. A thyroid carcinoma was an incidental finding in another patient. The sensitivity of PET/CT was 58% and specificity 83%. In 6 months following the baseline PET/CT, further sites of in-transit or systemic disease were identified in 10 patients (40%). Brain MRI did not alter the treatment plan or change the disease stage in any patient. Whole-body PET/CT improved staging in melanoma patients with S&ITM and changed the originally-contemplated treatment plan in 16%. MRI of the brain appeared not to be useful.

Computed tomography measurements of the lesser metatarsal heads: Anatomic considerations for surgeons performing distal metatarsal osteotomies.

BACKGROUND: The purpose of the current study was to provide a standardized, anatomical description of the lesser metatarsals to assist surgeons when planning distal metatarsal surgery and fixation. METHODS: Eighty CT scans were included for assessment, based on a priori power analysis. Patient age was a mean 52.7±16.6 years (24-83). Metatarsals two through five were assessed in all patients. Three independent observers completed measurements for all metatarsals. Three measurements were made on all metatarsals, including a vertical height and metatarsal head and neck measurements. Statistical analysis was performed (alpha value 0.05). Inter-observer reliability was assessed for all measurements and intra-class correlation (ICC) reported. RESULTS: A sequential decrease in metatarsal measurements was noted from the second to the fifth metatarsal. A mean vertical height measurement of 16.1±1.4mm (range, 13.4-19.4) was recorded for the second metatarsal, decreasing 13.0±1.1mm (range, 10.3-16.1) for fifth. There were no significant differences in metatarsal measurements based on gender in our study. Similar patient and metatarsal variability was seen head and neck measurements. Intraclass correlation coefficients (ICC) for metatarsal measurements were greater than 0.9 [95% CI; 0.936-0.991] correlation, denoting an 'excellent' interobserver reliability. CONCLUSION: This study provides a baseline anatomical description of the distal metatarsals. These findings, including the variation found between patients and between metatarsal two through five, are relevant to surgeons planning and performing distal metatarsal osteotomies.

Clinical and radiologic outcomes of the second-generation Trabecular Metal™ glenoid for total shoulder replacements after 2-6 years follow-up.

BACKGROUND: A porous tantalum glenoid component for total shoulder replacements was introduced in 2003 to promote biologic ingrowth. However, reports of component failure prompted design modifications. The purpose of this study is to present the largest series to date, of TSR with the second-generation Trabecular Metal™ glenoid component. METHOD: A radiologic and clinical evaluation of the second-generation TM glenoid was conducted in consecutive cases of 76 shoulders (66 patients) with a mean follow-up of 43.2 months (range 24-72 months). Pre-operative VAS score, patient self-assessed ASES score, active shoulder range of motion, and radiologic assessment were recorded. Patients were recalled for latest follow-up clinical and radiologic evaluation. RESULTS: On latest follow-up, the mean VAS scores (pre-op: 6.4-latest: 0.9) and ASES scores (pre-op: 36.9-latest: 88.5) improved. Active range of motion improved in all planes. There was no report of glenoid component migration, loosening, or humeral stem subsidence. The incidence of non-progressive radiolucency in the glenoid was 6.6 % (Franklin 1: 3 cases, Franklin 2: 2 cases). Post-operative complications involved dislocation (n = 2) which were reduced in ED, post-operative stiffness (n = 1), transient axillary nerve neuropraxia (n = 1), and supraspinatus tear which underwent arthroscopic repair at 16 months post-op. There were no revision surgeries for implant loosening nor glenoid component fracture at the peg-base plate junction. CONCLUSIONS: The modifications established in the second-generation TM glenoid resulted to improve early to mid-term survivorship and clinical outcomes in TSR, with promise of long-term implant stability through bony ingrowth. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

The Natural History of Biointerference Screw Cyst and New Bone Formation in Anterior Cruciate Ligament Reconstruction: 16-Year Follow-up.

BACKGROUND: A variety of fixation devices are available for anterior cruciate ligament reconstruction (ACLR). Bioabsorbable screws allow imaging postoperatively without image artefact, as with magnetic resonance imaging (MRI). There is also the perceived benefit of screw resorption and subsequent host tunnel bone ingrowth. PURPOSE/HYPOTHESIS: The purpose of this study was to document the natural history of poly L-lactic acid (PLLA) bioabsorbable interference screws. Manufacturers claimed that screws would be resorbed and replaced by new bone within 2 years. The hypothesis was that these screws take considerably longer to achieve this claim. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Ten consecutive patients undergoing routine ACLR with a PLLA bioabsorbable RCI screw (Arthrex) and a standard 4-strand hamstring graft technique were assessed via MRI and telephone questionnaire at 1, 2, 4, 7, 10, and 16 years postoperatively. RESULTS: At 4-year follow-up, no resorption of the screw or bone formation had occurred. At 7-year follow-up, absorption of 7 screws was complete, cyst formation had occurred in 3 patients, and 5 patients had new bone formation. At 10-year follow-up, all screws were reabsorbed, cyst formation was evident in only 2 cases, and 7 patients had evidence of new bone formation. At 16-year follow-up, cyst formation was only present in 1 patient, and all patients had evidence of new bone formation. All patients had an intact anterior cruciate ligament and had returned to preinjury sporting activity. CONCLUSION: PLLA bioabsorbable screws take longer to resorb than previously thought by the manufacturers (ie, 2 years). New bone formation is evident in 100% of patients by 16 years. Cyst formation does not occur in all patients with a bioabsorbable screw implant. In the 3 patients demonstrating the presence of a cyst, no associated adverse effects were found with regard to anterior cruciate ligament graft survival or instability.

Cartilage injury after acute, isolated anterior cruciate ligament tear: immediate and longitudinal effect with clinical/MRI follow-up.

BACKGROUND: Anterior cruciate ligament (ACL) tears have been implicated in the development of osteoarthritis. Limited data exist on longitudinal follow-up of isolated ACL injury. HYPOTHESES: All isolated ACL tears are associated with some degree of cartilage injury that will deteriorate over time. There is a threshold of magnetic resonance imaging (MRI)-detectable cartilage injury that will correlate with adverse change in subjective patient-reported outcome measures. STUDY DESIGN: Cohort study, Level of evidence, 2. METHODS: The authors conducted a prospective, observational analysis of 42 knees in 40 patients with acute, isolated ACL injury (14 treated nonoperatively, 28 by reconstruction) with imaging at the time of injury and yearly follow-up for a maximum of 11 years. Morphologic MRI and quantitative T2 mapping was performed with validated outcome measures. RESULTS: All patients sustained chondral damage at initial injury. The adjusted risk of cartilage loss doubled from year 1 for the lateral compartment and medial femoral condyle (MFC) and tripled for the patella. By years 7 to 11, the risk for the lateral femoral condyle was 50 times baseline, 30 times for the patella, and 19 times for the MFC. There was increased risk of cartilage degeneration over the medial tibial plateau (MTP) (P = .047; odds ratio = 6.23; 95% confidence interval [CI], 1.03-37.90) and patella (P = .032; odds ratio = 4.88; 95% CI, 1.14-20.80) in nonsurgical patients compared with surgically treated patients. Size of the bone-marrow edema pattern was associated with cartilage degeneration from baseline to year 3 (P = .001 to .039). Each increase in the MFC Outerbridge score resulted in a 13-point decrease in the International Knee Documentation Committee subjective knee score (P = .0002). Each increase in the MTP resulted in a 2.4-point decrease in the activity rating scale (P = .002). CONCLUSION: All patients with acute, traumatic ACL disruption sustained a chondral injury at the time of initial impact with subsequent longitudinal chondral degradation in compartments unaffected by the initial "bone bruise," a process that is accelerated at 5 to 7 years' follow-up.