Effect of chondrocalcinosis on the MR imaging of knee menisci.

OBJECTIVE: Our goal was to determine the influence of chondrocalcinosis on MR imaging in the detection of meniscal tears. MATERIALS AND METHODS: A retrospective review was performed of knee MR imaging and arthroscopy records from two university hospitals between 1996 and 1998. Seventy individuals had radiographic evidence of chondrocalcinosis and underwent knee MR imaging. Thirty-seven of these individuals had undergone arthroscopy for further evaluation of their symptoms. MR imaging sensitivity and specificity in the detection of medial and lateral meniscal tears were calculated in these 37 patients who had radiographic evidence of chondrocalcinosis and in a control group of 34 patients who underwent MR imaging and arthroscopy but did not have knee chondrocalcinosis. RESULTS: In the chondrocalcinosis group, MR imaging sensitivity, specificity, and accuracy for meniscal tear were 78%, 71%, and 78%, respectively, for the lateral meniscus, and 89%, 72%, and 81% for the medial meniscus. The control group showed sensitivity, specificity, and accuracy of 93%, 100%, and 97%, respectively, for the lateral meniscus and 100% in all cases for the medial meniscus. The MR imaging detection of meniscal tears in both the lateral and medial compartments combined is significantly poorer in the presence of chondrocalcinosis (p < 0.005). CONCLUSION: MR imaging sensitivity and specificity for detection of meniscal tear is decreased in the presence of meniscal chondrocalcinosis. Chondrocalcinosis appeared as a high-signal-intensity region on T1-weighted, intermediate-weighted, and inversion recovery sequences. The high signal of chondrocalcinosis on inversion recovery sequence is an interesting observation that to our knowledge has not been previously reported. Radiographic correlation with the MR imaging examination can help prevent overdiagnosing meniscal tears.

MR imaging of arthritides of the cervical spine.

Indications for MR imaging have broadened with the development of multiplanar capability, superb soft tissue contrast, and high sensitivity for detecting pathologic alterations. These developments are especially valuable in the analysis of the spine, where multiple anatomic structures reside, each with varying physical properties. MR imaging is unsurpassed in demonstrating early structural and proliferative changes that occur in inflammatory and related arthritides, and in evaluating complications that can cause significant morbidity, and even death. The role of MR imaging in the evaluation of cervical spinal arthritis continues to evolve, as its role in identifying patients for surgical intervention becomes clearer.

Progression of radiographic joint erosion during low dose corticosteroid treatment of rheumatoid arthritis.

OBJECTIVE: The reported prevention of joint damage during treatment with prednisolone 7.5 mg daily in patients with early rheumatoid arthritis (RA)3 may have important implications for management of RA. We evaluated this observation in another patient population. METHODS: Radiographic progression rates in paired hand radiographs were analyzed in 824 patients with RA who participated in a 3 year prospective, randomized clinical trial comparing the nonsteroidal antiinflammatory drugs (NSAID) etodolac (150 or 500 mg bid) and ibuprofen (600 mg qid). Disease modifying antirheumatic drugs (DMARD) were not permitted. Prednisone < or=5 mg daily was continued by 197 patients (mean dose 4.37 mg daily) who had started prednisone therapy at least 6 mo before study entry, but new prednisone starts were not allowed. Standardized hand/wrist radiographs were done yearly and at dropout; joint erosion and narrowing scores of 3 readers were averaged and progression rates were compared. RESULTS: Mean duration of RA was 3.6 years (range 1-7); patients' ages were 21-78 years; 71% were women. Among the 824 patients, those taking prednisone were more likely to have had previous DMARD, and at study entry had higher radiographic scores for joint erosion and joint space narrowing and slightly higher swollen joint counts, C-reactive protein values, and rheumatoid factor titers than those not taking prednisone. However, for the subgroup of 252 patients with RA duration of 12-24 months, prestudy radiographic scores were not different in those taking or not taking prednisone. The mean (+/-SD) monthly rate of increase in erosion scores was 0.228 +/-0.37 for the prednisone patients and 0.206+/-0.35 for patients not taking prednisone (p = 0.994 by ANCOVA). The subgroup with 12 to 24 months' disease duration at entry also showed no significant effect of prednisone treatment on erosion progression. CONCLUSION: Clinically indicated low dose prednisone did not prevent progressive radiographic damage in 197 NSAID treated patients whose physicians had initiated < or =5 mg daily before study entry. The risk/benefit ratio of chronic low dose prednisone in early RA remains uncertain.

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.

MR imaging of arthritides affecting the shoulder.

MR imaging has had a limited role in the evaluation of arthritis involving the shoulder, despite studies that have shown this technique to be more sensitive than radiography in the evaluation of osseous erosions and cartilage loss. Factors responsible for limiting the use of MR imaging are its relatively high cost, as well as its insensitivity to diminished osseous mineralization and subtle areas of calcification or hyperostosis. MR imaging findings of some arthropathies, however--such as synovial osteochondromatosis, PVNS, and amyloid arthropath--are highly characteristic, and help in determining both diagnosis and treatment. Physicians also should be aware that MR imaging is highly effective at diagnosing numerous "secondary" conditions common in patients with shoulder arthropathies, including rotator cuff rupture, synovial cyst formation, and osteonecrosis.

Magnetic resonance imaging of rheumatoid arthritis.

MR imaging is able to demonstrate both the structural changes that occur in rheumatoid arthritis and the inflammatory changes, including synovial proliferation and joint effusion. MR imaging can demonstrate erosion before it is visible on radiographs. Although MR imaging appears to be very helpful in assessing the severity of rheumatoid arthritis and its response to therapy, the optimal technique for this assessment and the ultimate clinical value of MR imaging have yet to be determined.

Pigmented villonodular synovitis.

Pigmented villonodular synovitis is a benign proliferative disorder of the synovium of uncertain cause. It may involve tendon sheaths, bursae, or joints, the latter occurring as diffuse involvement or a localized nodule. This article reviews the clinical features of the disorder and the imaging features of the disease, concentrating on the findings and utility of MR imaging.

The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study.

OBJECTIVE: To determine the incidence of radiographic knee osteoarthritis (OA) and symptomatic OA (symptoms plus radiographic OA), as well as the rate of progression of preexisting radiographic OA in a population-based sample of elderly persons. METHODS: Framingham Osteoarthritis Study subjects who had knee radiographs and had answered questions about knee symptoms in 1983-1985 were reexamined in 1992-1993 (mean 8.1-year interval) using the same protocol. Subjects were defined as having new (incident) radiographic OA if they developed grade > or = 2 OA (at least definite osteophytes or definite joint space narrowing). New symptomatic OA was present if subjects developed a combination of knee symptoms and grade > or = 2 OA. Progressive OA was diagnosed when radiographs showing grade 2 disease at baseline showed grade > or = 3 disease on followup. RESULTS: Of 1,438 participants in the original study, 387 (26.9%) died prior to followup. Of the 1,051 surviving subjects, 869 (82.7%) participated in the followup study (mean +/- SD age 70.8 +/- 5.0 at baseline). Rates of incident disease were 1.7 times higher in women than in men (95% confidence interval [CI] 1.0-2.7), and progressive disease occurred slightly more often in women (relative risk = 1.4; 95% CI 0.8-2.5) but rates did not vary by age in this sample. Among women, approximately 2% per year developed incident radiographic disease, 1% per year developed symptomatic knee OA, and about 4% per year experienced progressive knee OA. CONCLUSION: In elderly persons, the new onset of knee OA is frequent and is more common in women than men. However, among the elderly, age may not affect new disease occurrence or progression.

Replacement of "other" joints.

Replacement of larger joints other than the hip and knee has been relatively disappointing and remains in a developmental stage. In the small joints, initial enthusiasm for silicone rubber arthroplasty has diminished in all sites except the MCPs because of the recognition of the high frequency of silicone synovitis. Further research and development is ongoing. This article was intended to facilitate understanding of the choices of operative procedures, the types of available components, and particularly, the specifics of radiographic assessment of the success or failure of these "other" prostheses. We hope this information will be helpful in assessing postoperative radiographs, as "We only see what we look for and we only look for what we know."

Imaging techniques in rheumatoid arthritis.

Imaging methods have traditionally been the primary tools for documenting disease severity and progression. Radiographic methods are insensitive to early changes but eventually reflect the degree of bone destruction, cartilage space narrowing, and deformity that has occurred. Microfocal radiography is being investigated as a method to better define early erosive changes. Neither technique allows optimal examination of soft tissues (e.g., joint effusion, pannus, ligaments, and tendons). Magnetic resonance imaging (MRI) allows both soft tissues and bones to be examined. Articular cartilage imaging is currently under investigation. Despite its high cost, the noninvasive nature of MRI and the extensive information it provides, make this an exciting area for investigating the changes in rheumatoid arthritis and response to therapy.

The efficacy of routine head computed tomography (CT scan) prior to lumbar puncture in the emergency department.

The efficacy of using unenhanced head computed tomography (CT scans) as a routine screening procedure prior to lumbar puncture in the emergency department is studied retrospectively by comparing opening pressure during lumbar puncture to CT scan diagnosis in 42 patients. No correlation was found between CT scan findings and opening pressure.

Design and implementation of a new radiology consultation service in a teaching hospital.

The steady increase in costs related to testing has been a major factor in the overall growth of health care expenses. Concern is substantial about the excessive number of tests ordered by physicians without measurable improvement in patients' outcomes. This is of particular concern in teaching hospitals, because in addition to the direct impact on national health care expenditures, these are the institutions in which young physicians train and formulate test-ordering practices. Proper selection of imaging tests is a complex process that requires detailed information about the patient; specific questions to be answered; and knowledge of the characteristics of the test, including sensitivity, specificity, risks, and cost. To date, no systematic method exists for combining the expertise of the radiologist with that of the referring physician before the tests are selected. Therefore, we designed a new clinical service within the radiology department that allows formal, on-the-ward consultation to assist internal medicine housestaff in the selection of radiologic tests. The goal of this study was to assess the feasibility of this formal radiology consultation service and to determine how often its imaging recommendations were implemented for patients with complicated medical conditions.

Medical impact of unedited preliminary radiology reports.

PURPOSE: To determine the potential frequency of adverse patient outcomes resulting from erroneous preliminary radiology reports. MATERIALS AND METHODS: The authors determined the number of preliminary radiology reports that changed substantively between the preliminary and final version during a 10-day collection period. They analyzed 200 of 1,648 reports to determine the potential for adverse outcome. RESULTS: Only 5.6% of the preliminary radiology reports were changed substantively. Two percent of all reports contained changes that would have led to additional testing or treatment and, possibly, increased morbidity. CONCLUSION: Immediate electronic transfer of a preliminary radiology report results in a small but important number of adverse outcomes; however, if a final edited report follows within 24 hours and referring physicians are called whenever the preliminary report contains erroneous information, the benefits of rapid information transmission may outweigh the additional risks.

Distal loss of femoral bone following total knee arthroplasty. Measurement with visual and computer-processing of roentgenograms and dual-energy x-ray absorptiometry.

The changes in bone-mineral content in the distal aspect of a cadaveric femur that had been prepared for insertion of the femoral component of a total condylar knee prosthesis were evaluated with visual inspection and computer-processing of roentgenograms and with dual-energy x-ray absorptiometry. Seventeen small slices of bone, each three millimeters wide, were removed so that, finally, 89 per cent of the bone was lost from the distal femoral metaphysis. Standardized lateral roentgenograms of the specimen were made with use of a reference step-wedge of hydroxyapatite, and dual-energy x-ray absorptiometry studies were performed with the x-ray beam tangential to the interface. The roentgenograms were digitized and the bone mineral was measured with use of computer analysis. Dual-energy x-ray absorptiometry was performed with and without the femoral prosthesis in place, in order to determine the effect of the metallic prosthesis on the accuracy of the measurement. A bone loss of 25 per cent or more was identified visually by all five of the readers 100 per cent of the time; losses of 20 to 24 per cent, 15 to 19 per cent, 10 to 14 per cent, and 3 to 9 per cent were correctly identified 92, 75, 66, and 59 per cent of the time, respectively. The measurements of bone-mineral content that were obtained from the digitized roentgenograms were linearly correlated with the actual bone-mineral content (the ash content) (r = 0.97, p < 0.001) and were three times more accurate than the visual readings. The determinations of bone-mineral content with dual-energy x-ray absorptiometry correlated highly with the ash content (r = 1.00, p < 0.001) and were seven times more accurate than the visual readings. There was only a 4 per cent difference between the measurements with dual-energy x-ray absorptiometry made with the prosthesis in place and those made without it in place (p < 0.01). Dual-energy x-ray absorptiometry was the most accurate of the three methods and could detect the smallest experimentally created loss; computer-processing and visual-processing of roentgenograms detected losses of 8 per cent or more and 25 per cent or more, respectively. Dual-energy x-ray absorptiometry and computer-processing of the roentgenograms quantified the bone loss, while visual-processing could detect only the presence or absence of bone loss.(ABSTRACT TRUNCATED AT 400 WORDS)

Magnetic resonance imaging of arthritides affecting the shoulder.

MR imaging has thus far had a limited role in the evaluation of arthritis involving the shoulder. In certain cases, such as in amyloid and synovial osteo chondromatosis, however, MR imaging may be virtually diagnostic. It is likely that MR imaging will have an expanded role in the evaluation of arthritis in the future.

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.