Comparison of polytomography and computed tomography for fracture assessment.

OBJECTIVE: To compare polytomography (PT) and computed tomography (CT) for visualizing fractures and arthrodeses, with and without metal hardware, to determine whether CT could adequately replace PT. DESIGN AND PATIENTS: An ex vivo bovine model containing fractures in three planes, reduced with metal hardware, was created to compare fractures using PT and CT. The radiation dose at the skin surface was calculated for both examinations. For in vivo assessment, images of 14 patients who underwent both PT and CT (15 fractures, five arthrodeses) were coded, sorted, and independently read by four musculoskeletal radiologists. They rated the degree of certainty of their assessment. Time factors for patients and personnel and financial costs were also compared. RESULTS: In the ex vivo model the fractures were well seen on both PT and CT. The radiation dose was higher for PT than for CT. In vivo, the degree of certainty in assessment of fractures and arthrodeses was higher for PT than CT in studies in which metal hardware was present, but there was no significant difference in studies without metal hardware or in the combined (with and without hardware) studies. The patient's and technologist's time required to perform a PT examination was greater than that for CT. CONCLUSION: In the assessment of fractures and arthrodeses containing metal hardware, PT is recommended. For studies without hardware, CT is equivalent and can replace PT.

The effects of drug therapy on radiographic progression of rheumatoid arthritis. Results of a 36-week randomized trial comparing methotrexate and auranofin.

OBJECTIVE: To determine the effects of drug therapy (methotrexate [MTX] versus auranofin [AUR]) on radiographic progression in patients with active rheumatoid arthritis (RA). METHODS: We conducted a 9-month randomized, multicenter, double-blind trial comparing MTX and AUR. Standardized radiographs of the hands and wrists were obtained at baseline and at completion of the study. Four experienced bone radiologists graded the radiographs for erosions, joint space narrowing, erosion healing, and reparative bone formation. RESULTS: Two hundred eighty-one patients were enrolled in the study. Radiographs were available on 167 of the 183 who completed the trial. After 9 months of therapy, there was a significantly greater worsening of the erosion score in the AUR group (mean +/- SEM change of 1.67 +/- 0.4) compared with the change in the MTX group (0.60 +/- 0.3) (P = 0.040). There was also a significantly greater worsening of the joint space narrowing score in the AUR group compared with the MTX group (1.36 +/- 0.3 versus 0.42 +/- 0.2) (P = 0.007). There was no difference demonstrated between groups in healing of erosions or in reparative bone formation. CONCLUSION: The rate of radiographic progression in patients with RA, as measured by erosion score and joint space narrowing score, was demonstrated to be lower in those treated with MTX, as compared with AUR, over a 36-week period.

Lipohemarthrosis of the knee: a review of recent experiences.

The radiographs of 268 patients with knee trauma were retrospectively reviewed. In 15 patients with intraarticular fracture, the images demonstrated fat-fluid levels. In 28 other patients with intraarticular fracture, only joint effusion without a fat-fluid level was depicted. The presence of a fat-fluid level in the knee indicated fracture in all patients in whom it was seen. The absence of such a level, however, did not exclude intraarticular fracture.

Evaluation of a nonconstrained total shoulder prosthesis.

We reviewed the radiographs and medical records of 76 patients with 98 nonconstrained total shoulder prostheses: 68 were inserted for rheumatoid arthritis, 25 for osteoarthritis, and five for avascular necrosis. The radiographic follow-up averaged 36 months. Radiographic evidence of postoperative complications was noted in 37 (38%) of 98 shoulders: dislocation of the humeral head (six), upward migration of the humerus (24), loosening of the glenoid compartment (15), loosening of the humeral component (five), subsidence of the humeral component (seven), and heterotopic bone formation (six). Patients with a dislocated prosthesis had limitation of motion, poor function, and residual pain. No increase in pain was associated with proximal subluxation of the humerus. No correlations were found between any of the radiographic findings (the presence of radiolucent lines about the glenoid or humeral components, humeral subsidence, or ectopic ossification) and any of the clinical findings (pain relief, range of motion, motor power, or functional improvement).

Symptomatic intravertebral disc herniation (Schmorl's node) in the cervical spine.

A case of a Schmorl's node in the cervical vertebra causing neck pain is reported. An inflammatory focus was found on histological examination of Schmorl's node indicating a possible mechanism of pain production.

The value of conventional views and radiographic magnification in evaluating early rheumatoid arthritis.

Fifty-four patients with suspected early rheumatoid arthritis had radiographs taken of their hands and wrists in 4 views (posteroanterior [PA], oblique, reverse oblique, and Brewerton) using conventional techniques and, in the PA view, using radiographic magnification. The radiographs were "masked" and presented in random order to 2 radiologists specializing in bone and joint radiology who interpreted them for malalignment, erosions, joint space narrowing, and soft tissue swelling. The PA was the best conventional view for demonstrating malalignment, joint space narrowing, and soft tissue abnormalities; the Brewerton view was better for detecting erosive disease. Radiographic magnification was more sensitive than conventional films for evaluating erosive disease, but otherwise was no better than the conventional PA view. These results help the physician choose the radiologic technique or combination of techniques that is most likely to detect specific abnormalities.

Intravenous methylmethacrylate after total hip replacement.

In eight patients, radiographs made after total hip replacement revealed methylmethacrylate in the soft tissues of the thigh. In one of them the configuration of the density was that of a vein. In the other seven patients similar but less extensive soft-tissue densities were seen postoperatively. One patient had postoperative hypotension which was thought to be due to a myocardial infarction. In another patient, with a prior history of congestive heart failure, congestive heart failure developed again after total hip replacement. The relationship of these complications to the radiographic observations was not clear.

Computed tomography and conventional radiographs of the craniocervical region in rheumatoid arthritis. A comparison.

Radiographs and computed tomography (CT) scans of 12 patients with rheumatoid arthritis of the cervical spine were reviewed to determine whether CT provides additional information to that obtained from conventional radiography and tomography. Modalities were compared with respect to determination of the extent of erosion, C1-C2 subluxation, atlantoaxial impaction, and soft tissue findings. CT showed greater extent of erosion in 9 of 12 patients. In 11 patients with C1-C2 subluxation, CT and plain radiographs were both useful because it was necessary to demonstrate both sagittal and axial relationships. In the 5 patients with atlantoaxial impaction both CT and plain radiographs demonstrated the abnormal relationships between the odontoid and the foramen magnum. CT showed attenuation of the transverse ligament and the presence or absence of spinal cord compression, whereas plain radiographs did not. Nevertheless, significant new information regarding the spinal cord was obtained by CT in only 1 of the 12 patients. Computed tomography provides additional information about the rheumatoid cervical spine that is unobtainable by conventional modalities. In particular, CT demonstrates bone changes in the axial projection and facilitates evaluation of soft tissue, ligament, and spinal cord involvement. However, CT should be reserved for those instances in which plain radiographs and tomograms do not explain clinical findings.

Radiologic findings in late-onset systemic lupus erythematosus.

Systemic lupus erythematosus in the elderly has a different clinical and serologic course from that in young patients. Radiographic findings in patients in whom the diagnosis was made after age 50 were compared with findings in younger patients to see if the radiologic patterns are also different. The only significant radiographic difference between the two groups was that the older group had a greater incidence of soft-tissue swelling of the hands and wrists (p less than 0.001). There was no significant difference in osteopenia, erosion, soft-tissue calcification, alignment abnormalities, or intrathoracic findings. Of 24 patients over age 50, two developed lymphoma and another developed multiple myeloma. The data agree with clinical observations that there is a higher incidence of arthritis in late-onset lupus, but clinical findings of increased incidence of pleuropericardial disease are not confirmed radiographically. The coincidence of hematologic malignancy with late-onset lupus in this series is noteworthy.

Complications of intertrochanteric rotational osteotomy.

Intertrochanteric anterior rotational osteotomy is a recently developed surgical procedure to treat osteonecrosis of the femoral head. We reviewed the radiographic findings in four cases to acquaint radiologists with the usual appearance of the procedure and to assess surgical complications. In all cases, immediate postoperative radiographs showed rotation of the necrotic portion of the femoral head anteriorly so that it was no longer weight-bearing. Clinical and radiologic follow-up ranged from 12 to 30 months. In this time, three patients developed complications, including non-union of the osteotomy, further osteonecrosis with collapse of the femoral head, and worsening pain in the absence of progressive radiologic change. Radiology provides an important means of assessing rotational osteotomy, particularly in demonstrating sufficient rotation of the femoral head to assure nonweight-bearing by diseased bone. Also, surgical complications such as nonunion and hardware loosening may be identified. Nevertheless, the patient may deteriorate clinically even in the absence of radiologic demonstration of disease progression, and the absence of radiographic change does not assure a successful surgical outcome.

Prognostic features of atlantoaxial subluxation in rheumatoid arthritis patients.

The clinical and radiographic findings of 194 patients with rheumatoid arthritis and atlantoaxial (C1-C2) subluxation and/or atlantoaxial impaction (AAI) were reviewed. The condition of most patients with C1-C2 alignment abnormalities remained unchanged or became worse with time (i.e., the misalignment became fixed, subluxation increased, or AAI developed). The chance of developing upper cervical cord compression was not related to worsening per se, but to the degree of deformity. Upper spinal cord compression developed more often in men; when C1-C2 subluxation was greater than 9 mm; and in the presence of atlantoaxial impaction. The presence of lateral C1-C2 subluxation probably also contributes to the development of upper spinal cord compression. Settling of the skull and C1 onto C2 (AAI) were considered to be present when the anterior arch of C1 was abnormally low in relation to C2.

Radiographic findings in the hands in patients with systemic lupus erythematosus.

Hand radiographs of 59 patients with systemic lupus erythematosus (SLE) were examined. Thirty-four revealed radiographic abnormalities, most commonly periarticular soft-tissue swelling or demineralization. Alignment abnormalities, acral sclerosis, avascular necrosis, soft-tissue calcification and terminal tuft resorption were also seen. All patients with periarticular calcification or terminal tuft resorption had Raynaud's phenomenon. Clinical indicators of disease activity (including low serum complement levels) did not correlate with the presence or severity of radiographic abnormalities. Patients with abnormal radiographs generally were older at the time of diagnosis than those with normal studies.

Spontaneous fractures of the olecranon process in rheumatoid arthritis.

Spontaneous fractures through the olecranon process occurred in 3 patients with long-standing rheumatoid arthritis. In each case the elbow was severely damaged, particularly in the midportion of the trochlear notch, which was thinned either by erosion or cyst formation. The thin trichlear notch is the weak pivot point of a lever (the olecranon process) which pivots on the distal humerus. Excess stress on the lever, by the action of the triceps on the olecranon process, will produce a fracture at the weakest point: the midtrochlear notch.

Lesions resembling gout in patients with rheumatoid arthritis.

Although roentgenographic appearances are seldom important in establishing the diagnosis of rheumatoid arthritis or gout, atypical appearances of individual lesions may confuse the distinction between these two conditions. Sixteen patients with rheumatoid arthritis were selected to illustrate joint and soft tissue lesions which resemble gout. The lesions are divided into five broad categories on the basis of the appearance and sites of bone erosion as well as the nature of soft tissue changes. Symmetrical bilateral joint involvement was found to be especially helpful in distinguishing rheumatoid arthritis from gout.

Pseudogout in ochronosis. Report of a case.

Calcium pyrophosphate dihydrate crystals were identified in synovial fluid white blood cells during an episode of acute arthritis in a patient with ochronosis and chondrocalcinosis. Review of the histories and radiographs of 5 other patients with ochronosis demonstrated two additional instances of chondrocalcinosis. Both of these patients had episodes of arthritis consistent with pseudogout. This suggests that pseudogout, which has been found in increased incidence in some metabolic diseases, may also be more common in ochronosis.

Rheumatoid synovitis: complement and immune complexes.

The pattern of complement component utilization within the joint space of patients with RA is consistent with activation by immune complexes. Immunogluorescent studies of SF leukocytes revealed intracytoplasmic inclusions of immunoglobulins and complement components, particularly in cells from SF with low complement levels and containing materials which precipitated with either C1q and/or rheumatoid factor. RA patients with low levels of SF complement tended to have an unremitting course, subcutaneous nodules, and to have been treated with gold. Their joints had more periarticular demineralization, joint space narrowing, cortical impaction by X-ray; and synoviocytic giant cells, fibrosis, lymphocytes, congestion, and fibrin exudation by pathologic examination than did joints of RA patients without low levels of SF complement. Patients with systemic hypocomplementemia had active classical RA with evidence of severe joint involvement and vasculitis. These findings suggest that rheumatoid inflammation of joints is mediated by immunologic activation of the complement system.