Reliability and construct validity of the compatible MRI scoring system for evaluation of haemophilic knees and ankles of haemophilic children. Expert MRI working group of the international prophylaxis study group.

We tested the reliability and construct validity of the Compatible magnetic resonance imaging (MRI) scale for the evaluation of haemophilic knees and ankles and compared the diagnostic performance of MRI and plain film radiographs. Sagittal and coronal gradient-echo 1.5-T MR images of knees (n=22) and ankles (n=23) were obtained from boys (age range 4-16 years; mean 11 years) in two centres (Toronto, n=26; Europe, n=19). The MR images were independently read by four blinded radiologists on two occasions. Number of previous joint bleedings and laboratory level of severity of haemophilia were the reference standards for imaging assessment. Both components of the MRI scale demonstrated high inter- and intrareader intraclass correlation coefficients (progressive (P) scale, 0.91 and 0.94; additive (A) scale, 0.81 and 0.92 respectively). The correlation between the osteochondral domain of the MRI scale and patient's age was moderate. Otherwise, correlations between A- and P-scales and clinical laboratory measurements were weak. The areas under the curve (AUCs) used for discrimination of disease severity were similar for the A- and P-scales (AUCs used for mild disease, A-scale, 0.72+/-0.07; P-scale, 0.69+/-0.08; P=0.23; AUCs for severe disease, A-scale, 0.93+/-0.05; P-scale, 0.87+/-0.08; P=0.05). No differences were noted between the AUCs of the MRI and radiographic scales used for discrimination of late osteoarticular changes; MRI scales performed better for discrimination of early changes. In conclusion, both MRI scales demonstrated excellent reliability, poor convergent validity, and moderate and excellent validity for discrimination of mild and severe diseases respectively. Compared with radiographic scores, the MRI scales performed better for discrimination of early osteoarticular changes.

Evolution of the imaging tests in hemophilia with emphasis on radiography and magnetic resonance imaging.

Even before the discovery of X-rays in 1895 attempts were being made to classify the joint destruction that occurs in hemophilic arthropathy. The advent of radiography added impetus to the search for the optimum classification system. Subsequent attempts have included advanced imaging methods, especially magnetic resonance imaging (MRI). Because of its high spatial resolution and ability to visualize soft tissue abnormalities, MRI is ideally suited as the best way to classify arthropathy. A literature search was carried out to document and list all the imaging methods for hemophilic arthropathy that have been published up to the present. All published classification systems are discussed and listed in tables. MRI has superior imaging capability and will probably become the most important modality for radiological classification of hemophilic arthropathy in the future.

Reliability of progressive and additive MRI scoring systems for evaluation of haemophilic arthropathy in children: expert MRI Working Group of the International Prophylaxis Study Group.

Effective treatment of haemophilic arthropathy requires a detailed evaluation of joint integrity. Methodological assessment of magnetic resonance imaging (MRI) scores are needed to assure reproducibility of measurements when comparing results of clinical trials conducted in different centres. We compared the reliability of two MRI scoring systems for assessment of haemophilic arthropathy: one progressive system that displays the most severe change and one additive system that depicts osteochondral and soft tissue-related changes. A total of 47 1.5 T MRI examinations of knees (n = 21) and ankles (n = 26) of 42 haemophilic boys, age range, 22 months to 18 years, performed at different centres (Toronto, n = 20, Europe, n = 12 and Denver, n = 15) were independently reviewed by four radiologists at two occasions. Twenty-two examinations were from children <9 years and 25 from children >/=9. Sagittal and coronal gradient-echo (MPGR, 3D FLASH with fat saturation, GRASS) images were obtained. The MRI examinations of the ankle and knee studies presented with osteochondral abnormalities in 38.5% and 23.8% of the cases respectively. The two scoring systems demonstrated an excellent inter-reader [progressive, 0.88; additive (A, e, s and h components), 0.86] and intra-reader [progressive, 0.92; additive (A, e, s and h components), 0.93] reliability using intraclass correlation coefficients (ICCs). Although ICCs were slightly higher for knees when compared with ankles, and for older children when compared with younger children, all values fell within excellent inter- and intra-reader reliability categories. The two MRI scoring systems demonstrated a comparable reliability. This result constitutes the basis for further development of a combined MRI scoring system for assessment of haemophilic arthropathy, which incorporates progressive and additive components.

Consensus perspectives on prophylactic therapy for haemophilia: summary statement.

Participants in an international conference on prophylactic therapy for severe haemophilia developed a consensus summary of the findings and conclusions of the conference. In the consensus, participants agreed upon revised definitions for primary and secondary prophylaxis and also made recommendations concerning the need for an international system of pharmacovigilance. Considerations on starting prophylaxis, monitoring outcomes, and individualizing treatment regimens were discussed. Several research questions were identified as needing further investigation, including when to start and when to stop prophylaxis, optimal dosing and dose interval, and methods for assessment of long-term treatment effects. Such studies should include carefully defined cohorts, validated orthopaedic and quality-of-life assessment instruments, and cost-benefit analyses.

Radiological assessment of haemophilic arthropathy with emphasis on MRI findings.

Medical imaging of haemophilic joints is important for detecting abnormalities, grading their severity and selecting the appropriate therapy. The plain-film scoring systems for staging joint disease that were developed prior to the availability of magnetic resonance imaging (MRI) are inadequate for planning modern prevention and treatment. MRI is capable of delineating all of the soft tissue findings long before they are evident on plain radiographs. In this paper, an MRI scoring system is presented along with examples of joint effusion, haemarthrosis, synovial hypertrophy, haemosiderin deposition, erosions, cysts and cartilage loss. MRI is a powerful tool in the diagnosis, staging and treatment of patients with haemophilic joint disease.

Traumatic injuries: imaging of peripheral musculoskeletal injuries.

The current dominant role of conventional radiography must be reassessed at increasingly shorter intervals in view of the continuing emergence of new imaging modalities that are available to diagnose peripheral musculoskeletal injuries. In comparison with conventional radiography, digital radiographic techniques offer advantages for optimization of image quality and dose, such as a wider dynamic range and post-processing of images. Currently, digital luminescence radiography (storage phosphor radiography) is the most commonly used digital method for obtaining radiographs, using the established positioning projections and routines of the film-screen technique. A new process, radiography with flat-panel amorphous silicon detectors, is still under development. Computed tomography is a valuable tool for diagnosing injuries of the peripheral musculoskeletal system, especially when three-dimensional data sets are acquired; these allow reformating images in all planes desired (2D technique) or in a volumetric format (3D technique). Established indications for CT in the peripheral skeleton are hip fractures, wrist injuries and calcaneal fractures; however, CT may be used as a supplement to radiography in every region of the body. Sonography is beginning to play an increasingly important role in trauma. Muscle and tendon injuries are the most common indications, but worthwhile information can be gained of the shoulder, elbow, hip, and knee joints, supplementing conventional or digital radiography. Magnetic resonance imaging effectively visualizes traumatic changes of the skeleton and the peripheral soft tissues. It is the method of choice to detect occult fractures. It can be used to diagnose muscle and tendon injuries. Joint injuries, especially in the knee and the shoulder joint, are common indications for MRI in the posttraumatic setting.

Late clinical, plain X-ray and magnetic resonance imaging findings in haemophilic joints treated with radiosynoviorthesis.

The clinical, plain X-ray and magnetic resonance imaging (MRI) findings were studied in 13 haemophilic joints previously treated with radiosynoviorthesis. (32)P had been injected into the joints at a median of 16 years earlier in an attempt to halt recurrent haemorrhage. Prior to (32)P injection, the majority of joints demonstrated bone damage evident on plain X-ray, secondary to recurrent haemorrhage. At the follow-up evaluation we found plain X-rays were adequate to identify cysts, erosions and cartilage loss in these very damaged joints. MRI was superior to clinical examination and plain X-ray in identifying synovial hyperplasia and effusions.

MRI findings in haemophilic joints treated with radiosynoviorthesis with development of an MRI scale of joint damage.

We hypothesized that magnetic resonance imaging (MRI) scans taken prior to radiosynoviorthesis may be predictive of response to the procedure in persons with haemophilia. Specifically, response would be inversely related to the severity of synovial hyperplasia. Radiosynoviorthesis was administered to 21 joints with recurrent haemorrhage (target joints). A detailed self-report of haemorrhage history, joint evaluation with scoring according to the World Federation of Haemophilia orthopaedic joint and pain scales, plain radiographs, and MRI studies of the joints were performed pre- and post-radiosynoviorthesis. To augment comparison of the MRI findings to those assessed using the Arnold-Hilgartner and Pettersson scales, a provisional MRI scale for evaluation of haemophilic arthropathy was designed. We found the MRI findings prior to the procedure were not predictive of clinical response; independent of the severity of synovial hyperplasia, most joints bled less and showed improvement by the WFH orthopaedic score. There was generally no change in the severity of synovial hyperplasia after the procedure. We conclude that MRI evaluation is not routinely indicated prior to radiosynoviorthesis.

Premature osteoarthrosis in professional dancers.

OBJECTIVE: The purpose of this study was to determine whether arthrosis begins at an unusually early age in professional dancers; if there is an association between hypermobility and osteoarthrosis in dancers; and if osteoarthrosis is a contributing factor to retirement from a professional career in this population. DESIGN: Dance and injury history; physical examinations of back, lower extremities, and ligamentous laxity; and radiographs of lower extremity joints were performed in retired dancers. The dancers' radiographs were compared to those of age-matched nondancers. The radiologist was blinded to the origin of the radiographs. PARTICIPANTS: Fourteen retired dancers aged 27 to 46 years who had performed professionally for a minimum of 10 years were included in the study. Thirty-six age-matched nondancers with injuries or pain in various lower extremity joints were used as controls. MAIN OUTCOME MEASURES: This study measured radiographic findings of osteoarthrosis, including sclerosis, joint space narrowing, osteophytes, and subchondral cysts; hypermobility (after Klemp) as manifested by > 3 of 5 tests being positive; and the dancers' reasons for retirement. RESULTS: Changes of arthrosis were found in 34 of 56 joints in 14 dancers and in 3 of 36 joints in 36 nondancers. Hip calcifications were found in 10 hips in 7 dancers and in 1 nondancer's hip. None of the participants in this study was hypermobile or had retired because of arthrosis. CONCLUSIONS: The prevalence of arthrosis in knees, ankles, and first metatarsophalangeal joints in young dancers was increased when compared to that of nondancers in the same age group. Arthrosis does not necessarily cause retirement from a performance career.

Knee version associated with anterior knee pain.

Version of the knee in the presence and absence of anterior knee pain was evaluated by computed tomography in this study. Version of the knee is defined as the static rotation of the tibia with respect to the femur in full knee extension. Fourteen patients in whom conservative management for anterior knee pain failed were compared with 14 volunteers with no symptoms. Computed tomography images of the femoral condyles and tibial plateau were obtained with the knee extended. The angle between the bicondylar and posterior tibial axes was measured. This angle, representing external rotation of the tibia relative to the femur, was increased significantly in patients with symptoms (7 degrees) compared with volunteers with no symptoms (1 degree). This increased knee version identifies a unique morphologic characteristic of the knee with anterior pain.

Skin and bones: dermatologic conditions with skeletal abnormalities.

OBJECTIVE: Radiologists should be aware of the fact that many dermatologic conditions have associated skeletal abnormalities. This pictorial essay seeks to acquaint radiologists with these associations. DESIGN: Twenty-four skin and bone conditions are portrayed and discussed under the headings of: disorders of the epidermis, disorders of the dermis, disorders of the sebaceous glands, disorders of pigmentation, disorders of the nails, tumors, the phakomatoses, immunologic-allergic disorders, and infections. In addition, a table is provided as an expanded listing of conditions with such associations. CONCLUSION: This pictorial essay will help radiologists and other practitioners become familiar with dermatologic conditions that have associated skeletal abnormalities.

Hip pain in an adolescent.

We have described a case of osteomyelitis of the ischium with extension into the adjacent soft tissues and abscess formation. Diagnosis and treatment were initially delayed due to the assumption that edema in the thigh muscles seen on initial MRI represented polymyositis. Subsequent radiographs demonstrated a destructive lesion containing a sequestrum within the ischium, indicative of osteomyelitis. It was, however, the MRI imaging that dramatically demonstrated the full extent of the complicating abscess which extended downward to mid-thigh and upward under the gluteal muscles almost to the top of the iliac crest. This proved to be an invaluable guide for the surgeon.

Location of the femoral sulcus in the osteoarthritic knee.

Morphology of the distal femur is characterized in patients with osteoarthritis to identify an etiology for the high incidence of patellar till, subluxation, and failure noted in total knee arthroplasty. This study demonstrates that the sulcus of the trochlear groove is not located in the midline as traditionally represented, but is lateral to the midline in both osteoarthritic and normal knees. The significance of this is that the patella will presumably track lateral to the midline unless surgically realigned, contributing to the prevalence of patellar tracking problems associated with symmetric femoral components with centralized sulci used in contemporary total knee arthroplasty.