Sandwich Technique for Large Osteochondral Lesions of the Knee.

OBJECTIVE: To evaluate whether a sandwich technique procedure for large osteochondral lesions (OCL) of the medial femur condyle reduces clinical symptoms and improves activity level as well as to assess repair tissue integration on MRI over 2 years. DESIGN: Twenty-one patients (median age: 29 years, 18-44 years) who received matrix-associated autologous chondrocyte transplantation (MACT) combined with cancellous bone grafting at the medial femur condyle in a 1-step procedure were prospectively included. Patients were evaluated before surgery (baseline) as well as 3, 6, 12, and 24 months postoperatively, including clinical evaluation, Lysholm score, Tegner Activity Rating Scale, and MRI with Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and a modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). RESULTS: Seventeen patients were available for the 24-month (final) follow-up (4 dropouts). Lysholm significantly improved from 48 preoperatively stepwise to 95 at final follow-up (P < 0.05). Tegner improvement from 2.5 at baseline to 4.0 at final follow-up was not significant (P = 1.0). MOCART score improved significantly and stepwise from 65 at 3 months to 90 at 24 months (P < 0.05). Total WORMS improved from 14.5 at surgery to 7.0 after 24 months (P < 0.05). Body mass index and defect size at surgery correlated with total WORMS at final follow-up (P < 0.05) but did not correlate with clinical scores or defect filling. CONCLUSION: MACT combined with cancellous bone grafting at the medial femoral condyle reduces symptoms continuously over 2 years. A 1-step procedure may reduce perioperative morbidity. However, despite improvements, patients' activity levels remain low, even 2 years after surgery.

No healing improvement after rotator cuff reconstruction augmented with an autologous periosteal flap.

PURPOSE: To show descriptive clinical and magnetic resonance (MR) imaging results after an additional periosteal flap augmentation in mini-open rotator cuff reconstruction and to evaluate potential healing improvement at long-term follow-up. METHODS: Twenty-three patients with degenerative rotator cuff tears were followed after receiving a mini-open single-row repair with a subtendinous periosteal flap augmentation. Data were collected preoperatively, after 12 months and after 11 years. Clinical examination, simple shoulder test (SST), Constant-Murley Score (CS), ultrasonography examination and 3T MR imaging were performed. RESULTS: Out of 23 patients, 20 were available for short-term and 19 for final follow-up at a median of 11.5 years (range 10.4-13.0). Questions answered with "yes" in SST improved from baseline 5.0 (range 1.0-8.0) to short 10.5 (range 8.0-12.0) and final follow-up 12.0 (range 7.0-12.0). CS improved from 53.5 (range 25.0-66.0) to 80.8 (range 75.9-89.3) and finally to 79.8 points (range 42.3-95.4). Improvement was highly significant (p < 0.05). Severe retears were found in 9/19 patients. Ossifications along the refixed tendon were noticed in 8/19 cases. Ossifications did not correlate with clinical outcome. At final follow-up, patients with retears seemed likely to have lower strength values in CS (mean ± SD) than patients without retears (7.3 ± 4.1 vs. 12.8 ± 5.3; p < 0.05). CONCLUSION: No positive effect on improving healing response in rotator cuff refixation with a periosteal flap augmentation could be found. Retear rate is comparable to that of conventional rotator cuff refixation in the published literature. Ossifications along the tendon, without negatively affecting the clinical outcome, were seen. This invasive technique cannot be advised and should not be used anymore. LEVEL OF EVIDENCE: IV.

[Advanced cartilage imaging for detection of cartilage injuries and osteochondral lesions]. / Dezidierte Knorpelbildgebung zur Detektion von Knorpelverletzungen und osteochondralen Läsionen.

BACKGROUND: Osteochondral defects represent a main risk factor for osteoarthritis of the ankle. OBJECTIVES: The aim of this article is to provide an overview of current optimal clinical cartilage imaging techniques of the foot and ankle and to show typical osteochondral injuries on imaging. MATERIALS AND METHODS: A thorough literature search was performed and was supported by personal experience. RESULTS: Cartilage imaging of the foot and ankle remains challenging. However, advanced morphological and quantitative magnetic resonance (MR) imaging techniques may provide useful clinical information, for example, concerning cartilage repair surgery. Compared to MRI, MR arthrography (MR-A) and CT arthrography (CT-A) have higher sensitivity with respect to detection of osteochondral defects. Regarding smaller joints of the foot, mainly advanced osteoarthritic changes are detected on conventional radiography; only in rare cases, MR and CT imaging of these smaller joints is of relevance. CONCLUSIONS: While at the smaller joints of the foot cartilage imaging only plays a minor role, at the ankle joint cross-sectional cartilage imaging using CT and MRI becomes more and more important for clinicians due to emerging therapeutic options, such as different osteochondral repair techniques.

[Spindle-cell osteosclerotic bone lesion with MDM2 amplification]. / Spindelzellige osteosklerotische Knochenläsion mit MDM2-Amplifikation.

This case report presents an osteosclerotic bone lesion in a 49-year-old man with MDM2 amplification. The final diagnosis shows metastasis to the bones from stomach cancer. In primary bone tumours, the MDM2 amplifications observed have been described for many other tumour entities as well, and therefore do not exclude bone metastasis from a carcinoma.

[Acute sports injuries and chronic overuse stress damage to the forefoot and midfoot]. / Akute Sportverletzungen und chronische Überlastungsschäden an Vor- und Mittelfuß.

Sports injuries of the foot can occur as sequelae of acute trauma or chronic overuse. Besides clinical examination, imaging plays a major role in the detection of structural abnormalities and the differential diagnostics. This article reviews the most important sports-related soft tissue and bone pathologies of the forefoot and midfoot together with their typical findings on radiography, ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI).

[Association between Hindfoot Alignment and Localisation of Osteochondral Lesions of the Talus]. / Zusammenhang der Rückfußachse mit der Lokalisation von osteochondralen Läsionen am Talus.

BACKGROUND: Osteochondral lesions (OCL) of the talus show a distinct distribution pattern. Vascular, metabolic, idiopathic, and biomechanical factors have been proposed as influencing factors. However, the association of hindfoot alignment and the location of talar OCL is not known. MATERIALS AND METHODS: In 22 patients undergoing autologous osteochondral transplantation for OCL of the talus we collected preoperative data on radiographic hindfoot alignment and clinical performance using the AOFAS score and the VAS for pain. The inter-observer reliability between two investigators was calculated. The association between hindfoot alignment and OCL location was statistically assessed. RESULTS: The preoperative AOFAS score was 64.1 ± 13.9 points and the VAS 5.1 ± 1.4. The mean measurement difference between the two observers was less than 0.5 degrees and the reliability of the measurements was good with a high association (κ = 0.83). Surprisingly, the location of the OCL of the talus was independent from hindfoot alignment (p = 0.766). CONCLUSION: In our study the hindfoot alignment showed no association with the location of OCL of the talus. Hence, hindfoot alignment per se does not correlate with the localisation of talar OCL.

[Diagnosis of malignant bone and soft tissue tumors]. / Diagnostik von malignen Knochen- und Weichteiltumoren.

Primary sarcoma of bone is a rare entity but nevertheless a significant cause of mortality in children and adolescents. The focus of the preoperative evaluation is to set up a histological diagnosis, define local tumor extent and develop a therapy regimen. In addition to patient history and clinical findings a radiograph in two orthogonal planes is still of great importance. MRI plays a major role in the further clarification of the diagnosis, while CT is valuable in the diagnosis of tumors of the axial skeleton as well as in systemic staging. A PET-CT can be performed to obtain an overview of further tumor sites. Open bone biopsy is the final diagnostic step and should be carried out at the institution where the definitive treatment will be performed. Complications such as fracture, neural lesions and spread of tumor cells are relatively rare if the biopsy is performed appropriately; however, patients should be instructed to strictly avoid weight-bearing on the affected extremity.

[Autologous transfer of the posterior femoral condyle for large osteochondral lesions of the knee: 5-year results of the Mega-OATS technique]. / Der autologe Transfer der posterioren Femurkondyle bei ausgedehnten osteochondralen Schäden des Knies : 5-Jahres-Ergebnisse der Mega-OATS-Technik.

BACKGROUND: Large osteochondral defects of the weight-bearing zones of the femoral condyles in young and active patients were treated by autologous transfer of the posterior femoral condyle. This technique is a salvage procedure and aims at pain-free mobility of patients. MATERIAL AND METHODS: Between July 1999 and December 2000, 18 patients were operated on. Sixteen patients were evaluated using the Lysholm score. X-rays were done, and eight individuals underwent magnetic resonance imaging (MRI) analysis. The average age at the date of surgery was 37.4 (15-59) years, and the mean follow-up time was 55.2 (46-62) months. The mean defect size was 5.4 cm(2) (3.1-7.1). Trauma or osteochondrosis dissecans was pathogenetic in 81%. RESULTS: The Lysholm score showed a significant (p=0.001) increase from a preoperative median of 65.0 to a postoperative median of 86.0 points. Fifteen patients returned to sport activities. X-rays showed a rounding of the osteotomy edge in 12 patients and a partial bone-dense remodelling of the posterior femoral condyle in 11 patients. All MRI examinations showed vital and congruent grafts. CONCLUSION: Thus, the procedure is recommended for treating large and deep focal osteochondral lesions in the weight-bearing zone of the femoral condyle.

[Shoulder injuries in overhead sports]. / Schultergelenkverletzungen bei Uberkopfsportarten.

Overhead sport places great demands on the shoulder joint. Shoulder pain in overhead athletes and throwers can in the majority of cases be attributed to lesions resulting from chronic overuse of tendons and capsuloligamentous structures or to sequels of microinstability and secondary impingement. Due to its great impact on therapeutic decisions, imaging in athletes with unclear shoulder pain is a challenge. In this connection, magnetic resonance (MR) arthrography represents the cross-sectional imaging modality of first choice, as it allows depiction and exclusion of pathologic alterations of all relevant joint structures with sufficient confidence.This article reviews the biomechanical and clinical aspects and MR arthrographic features of the most common shoulder pathologies in overhead athletes, including biceps tendinopathy, superior labral anterior-posterior (SLAP) lesions, rotator cuff lesions, as well as extrinsic and intrinsic impingement syndromes.

[Ultrasound-guided intraarticular injection for MR arthrography of the shoulder]. / Ultraschallgesteuerte intraartikuläre Kontrastmittelapplikation für die MR-Arthrografie der Schulter.

PURPOSE: To evaluate ultrasound guidance for intraarticular contrast injection via an anterolateral approach in comparison with fluoroscopic guidance. MATERIALS AND METHODS: Contrast agent injection was performed in 40 consecutive patients, 20 under sonographic guidance and 20 under fluoroscopic guidance. None of the patients had previous shoulder surgery. The procedure time was measured and the efficiency of joint distension, incidence of extravasation and intraarticular air on the consecutive MR arthrograms were assessed by three blinded radiologists with musculoskeletal radiology experience. Statistical analysis was performed using the Kruskal-Wallis test. RESULTS: Intraarticular contrast injection was successfully accomplished in all 40 patients. Subsequent MR arthrograms did not show any significant difference between sonographic and fluoroscopic guidance with respect to diagnostic quality, joint distension (p=0.6665), intraarticular air bubbles (p=0.1567) and occurrence of contrast extravasation (p=0.8565). The mean duration of ultrasound-guided injection was 7:30 min compared to a shorter procedure time of 4:15 min for fluoroscopic guidance. In both groups, no procedural complications were observed. CONCLUSION: Ultrasound-guided injection for MR arthrography of the shoulder via an anterolateral approach represents a simple, safe, and effective technique which yields comparable results to those of injection under fluoroscopic guidance, but is slightly more time-consuming.

[Indications for CT and MR arthrography--recommendations of the Musculoskeletal Workgroup of the DRG]. / Indikationen der MR- und CT-Arthrografie--Empfehlungen der AG Muskuloskelettale Radiologie der DRG.

The ongoing discussion about CT and MR arthrography is at least in part due to the lack of definite guidelines. The intention of the musculoskeletal workgroup of the DRG (Deutsche Röntgengesellschaft) was the establishment of recommendations for general guidance. After review of the recent literature, the indications for arthrographic examinations were discussed during a consensus meeting. Since the published data are insufficient and partially contradictory, no precise statements could be extracted from the literature. Therefore, the proposed recommendations are mainly based on expert opinions. In this review the main statements of the published literature are summarized and the recommendations of the musculoskeletal workgroup of the DRG are presented.

[Persistent knee pain and palpable tumor in the popliteal fossa]. / Persistierende Knieschmerzen und palpabler Tumor in der Kniekehle.

The case of a female Patient with increasing pain and a palpable mass in the right popliteal fossa shows the spectrum of possible differential diagnoses for the radiologist. The diagnosis of a juxtaarticular myxoma made on the interpretation of conventional x-ray and magnetic resonance imaging was finally confirmed by biopsy.

[Whole-body MRI in children with langerhans cell histiocytosis for the evaluation of the skeletal system]. / Ganzkörper-MRT bei Langerhans-Zell-Histiozytose im Kindes- und Jugendalter zur Beurteilung des Skelettsystems.

PURPOSE: The usefulness of whole-body MRI (WB-MRI) for the detection of skeletal lesions in patients with Langerhans cell histiocytosis should be documented on the basis of case presentations. MATERIALS AND METHODS: In six patients with histologically proven Langerhans cell histiocytosis, 14 WB-MRI examinations were performed to evaluate the skeletal system within disease staging (6 primary, 8 follow-up examinations). The examinations were performed on a 1.5 Tesla, 32-channel whole-body scanner. The examination protocol consisted of T 1-weighted and STIR sequences in coronal and sagittal orientation. For comparison, radiographs of the initial skeletal lesions and those that were additionally detected on WB-MRI were available. RESULTS: In 4 patients no additional skeletal lesions were found on WB-MRI besides the initial lesion leading to the diagnosis of unifocal single system disease. In 2 patients WB-MRI was able to identify additional skeletal lesions. In a 5 S year-old boy with the primary lesion located in the cervical spine, a second lesion was detected in the lumbar spine on the initial scan and in the skull and proximal femur during follow-up examination. In a 12 year-old girl with a primary lesion of the thoracic spine, WB-MRI diagnosed additional lesions in the pelvic bone and the tibia. In both patients the diagnosis of multifocal skeletal involvement led to chemotherapy. During follow-up examination, the healing response under therapy could be demonstrated. Comparison with conventional imaging showed that especially lesions located in the spine or the pelvis were not detectable on radiographs even when knowing the MR results. CONCLUSION: The extent of skeletal involvement in Langerhans cell histiocytosis has crucial impact on therapy and prognosis. Whole-body MRI has been reported to be an established method for the evaluation of disseminated skeletal disease with distinct advantages over conventional radiography and bone scintigraphy. Our results suggest that WB-MRI should also be the imaging modality of choice for the assessment of skeletal involvement in children with Langerhans cell histiocytosis.

[MR imaging of the knee]. / MRT des Kniegelenks.

Since its introduction into clinical use, magnetic resonance imaging (MRI) has become well established in the diagnosis of injuries of the knee joint and has replaced diagnostic arthroscopy as the primary evaluation method. Traumatic lesions of the ligaments, menisci, and articular surfaces are common injuries that can be confidently detected using MRI. This article reviews the basic principles of the examination technique of the knee, the normal MRI anatomy of the internal joint structures, and the typical findings in injuries of the cruciate ligaments, collateral ligaments, and mensci, in traumatic dislocation of the patella, and in acute osteochondral lesions.

[Soft tissue carcinoma. Epidemiology, diagnostics and therapy]. / Weichteilsarkome. Epidemiologie, Diagnostik und Therapie.

The treatment of soft tissue sarcoma requires an individually tailored, multimodal therapy due to the high variability in the clinical situation. Resection is the usual treatment for patients with superficial, low grade tumors with a diameter of <5 cm. For intermediate grade, differentiated lesions, resection with negative resection edges combined with radiotherapy attains an almost 80% total survival rate. For patients with high grade sarcoma of >5 cm, local control can be attained by resection and radiotherapy, however every second patient will develop metastases. Patients with a local recurrence should consider a new resection. Radiotherapy is the more effective the lower the remaining postoperative tumor burden.