The reliability of the patellotrochlear index on magnetic resonance imaging for measuring patellofemoral height.

BACKGROUND: The purpose of this study was to determine the inter- and intra-observer reliability of the patellotrochlear index (PTI) on magnetic resonance images (MRI) in patients with patellofemoral pain. The correlation between the PTI measured on MRI and the modified Insall-Salvati (MIS) ratio measured on radiographs was also assessed. METHODS: The PTI was assessed on MRI images and the MIS ratio on radiographs of 66 knees of 62 patients. Assessment was performed by two orthopaedic surgeons, one orthopaedic surgery registrar, two radiologists and one radiology registrar. Correlation coefficients, standard errors of measurement and limits of agreement were calculated for the PTI. To assess the association between the PTI and the MIS ratio, the Pearson's correlation coefficient was calculated. RESULTS: The PTI showed good interobserver reliability (intraclass correlation coefficient (ICC) 0.79; 95% confidence interval (CI) 0.73-0.85) and excellent intra-observer reliability (ICC 0.90; 95% CI 0.89-0.91). The standard error of measurement was 0.05 and limits of agreement with the mean ± 0.09. A very weak and not significant correlation was found between the PTI and the MIS (r = 0.02; P = 0.77). CONCLUSIONS: The PTI showed good interobserver reliability and excellent intra-observer reliability. In order to conclude which measurement method of assessing patellar height is truly the most reliable, future studies should investigate agreement parameters (standard error of measurement, limits of agreement) besides solely correlation coefficients. We found a very weak correlation between the PTI and the MIS which suggests that at least one index has poor validity. Future validity studies on indices to assess patellar height are necessary.

Superior dislocation of the patella: a pathognomonic finding and review of literature.

A 59-year-old woman with a painful right knee that became locked in extension after a trivial trauma was seen at the emergency room. This was caused by unloaded hyperextension in bed. She was diagnosed with a superior dislocation of the patella. A closed reduction was performed, but a recurrent episode was seen within a week. An arthroscopy was performed, in which the causative osteophytes were removed. In the 12-month follow-up after treatment, no recurrence was seen. A superior dislocation of the patella is caused by patellofemoral osteophytes that interlock. This can cause a degenerative knee to become locked in extension. Beside interlocking osteophytes of the patella and the distal femur, the superior part of the patella is tilted away from the femur. This is caused by the pull of the patella tendon and the simultaneous relaxation of the quadriceps tendon. This is a pathognomonic finding on radiographs that, to the best of our knowledge, has been identified but not been appreciated as such in previous reports. As illustrated in this report, a superior dislocation of the patella can easily be recognized on physical examination and radiographic imaging alone when familiar with the specific abnormalities. This will reduce unnecessary diagnostic imaging studies and delay in treatment. This case report illustrates a recurrent case of superior dislocation of the patella. We summarize and evaluate previous reports, discuss trauma mechanisms, physical examination, classification, and treatment including recurrent cases. After reading this case report the reader will be able to diagnose a superior dislocation of the patella with near certainty on physical examination and radiographic imaging of the knee alone.

Dual energy CT: added value in gouty arthritis.

Gouty arthritis is an inflammatory reaction as a result of monosodium urate crystal deposition in synovial fluid and periarticular soft tissue. It is the most common form of inflammatory arthritis with an estimated prevalence of 5 per 1000 in the USA. Clinical diagnosis is difficult and definite diagnosis with positive urate crystal aspiration often is made late in the disease process. Dual energy computer tomography (DECT) is a relative new non-invasive imaging modality that is able to distinguish urate crystals from calcium in soft tissue and synovial fluid. In this case report we describe the potential of DECT in gout by clarifying the technical background and present two cases in which DECT confirms the clinical diagnosis and shows the extend of the disease. Although more extensive studies should be done to validate DECT in diagnosing gout, the preliminary results in diagnosing gout, determining the extensiveness and monitoring therapy are promising.

Regional heterogeneity changes in DCE-MRI as response to isolated limb perfusion in experimental soft-tissue sarcomas.

Experimental evidence supports an association between heterogeneity in tumor perfusion and response to chemotherapy/radiotherapy, disease progression and malignancy. Therefore, changes in tumor perfusion may be used to assess early effects of tumor treatment. However, evaluating changes in tumor perfusion during treatment is complicated by extensive changes in tumor type, size, shape and appearance. Therefore, this study assesses the regional heterogeneity of tumors by dynamic contrast-enhanced MRI (DCE-MRI) and evaluates changes in response to isolated limb perfusion (ILP) with tumor necrosis factor alpha and melphalan. Data were acquired in an experimental cancer model, using a macromolecular contrast medium, albumin-(Gd-DTPA)45. Small fragments of BN 175 (a soft-tissue sarcoma) were implanted in eight brown Norway rats. MRI of five drug-treated and three sham-treated rats was performed at baseline and 1 h after ILP intervention. Properly co-registered baseline and follow-up DCE-MRI were used to estimate the volume transfer constant (K(trans) ) pharmacokinetic maps. The regional heterogeneity was estimated in 16 tumor sectors and presented in cumulative map-volume histograms. On average, ILP-treated tumors showed a decrease in regional heterogeneity on the histograms. This study shows that heterogenic changes in regional tumor perfusion, estimated using DCE-MRI pharmacokinetic maps, can be measured and used to assess the short-term effects of a potentially curative treatment on the tumor microvasculature in an experimental soft-tissue sarcoma model.

Heterogeneity in DCE-MRI parametric maps: a biomarker for treatment response?

This study aims to quantify the heterogeneity of tumour enhancement in dynamic contrast-enhanced MRI (DCE-MRI) using texture analysis methods. The suitability of the coherence and the fractal dimension to monitor tumour response was evaluated in 18 patients with limb sarcomas imaged by DCE-MRI pre- and post-treatment. According to the histopathology, tumours were classified into responders and non-responders. Pharmacokinetic (K(trans)) and heuristic model-based parametric maps (slope, max enhancement, AUC) were computed from the DCE-MRI data. A substantial correlation was found between the pharmacokinetic and heuristic model-based parametric maps: ρ = 0.56 for the slope, ρ = 0.44 for maximum enhancement, and ρ = 0.61 for AUC. From all four parametric maps, the enhancing fraction, and the heterogeneity features (i.e. coherence and fractal dimension) were determined. In terms of monitoring tumour response, using both pre- and post-treatment DCE-MRI, the enhancing fraction and the coherence showed significant differences between the response group and the non-response group (i.e. the highest sensitivity (91%) for K(trans), and the highest specificity (83%) for max enhancement). In terms of treatment prediction, using solely the pre-treatment DCE-MRI, the enhancing fraction and coherence discriminated between responders and non-responders. For prediction, the highest sensitivity (91%) was shared by K(trans), slope and max enhancement, and the highest specificity (71%) was achieved by K(trans). On average, tumours that responded showed a high enhancing fraction and high coherence on the pre-treatment scan. These results suggest that specific heterogeneity features, computed from both pharmacokinetic and heuristic model-based parametric maps, show potential as a biomarker for monitoring tumour response.

High-resolution ultrasonography of the cutaneous nerve branches in the hand and wrist.

Ultrasonography can be used in the diagnosis of various neuropathies, including nerve injury. Nerves often involved in traumatic and iatrogenic injury are small cutaneous branches in the hand and wrist, which cannot be seen in detail using current ultrasound probes. This study explored the potential of high-resolution ultrasonography in seeing these nerve branches in the human. The VisualSonics Vevo 770 system with a 15-82.5 MHz probe was compared to a commonly used 5-12 MHz probe and ultrasound machine. The accuracy was validated by ultrasound guided dye injection into cadaver nerves, with subsequent anatomical dissection and verification. Results were confirmed in two healthy volunteers. The Vevo 770 system was able to accurately identify the small cutaneous nerves. It could also depict the median nerve and its fascicles in greater detail. This may be useful for clinical diagnosis, localisation and follow-up of neuropathies and nerve injuries.

High resolution wrist MR arthrography at 1.5T.

MR arthrography of the wrist is a valuable tool for the diagnosis and evaluation of a wide spectrum of acute and chronic articular disorders.The method has the potential of replacing diagnostic arthroscopy for the evaluation of the triangular fibrocartilage complex and the intrinsic and extrinsic ligaments. High resolution MR imaging with a dedicated coil is essential for detecting partial thickness tears. Abnormalities, such as leakage of injected contrast agent from one compartment into another are common in asymptomatic subjects. An optimal communication concerning clinical symptoms between the radiologist and referring clinician is essential not to overreport abnormalities without clinical importance. Awareness of normal variants and pitfalls is essential. Combining iodinated and gadolinium based contrast agents for MR arthrography may have additional value.

Soft tissue sarcomas at a glance: clinical, histological, and MR imaging features of malignant extremity soft tissue tumors.

Soft tissue sarcomas comprise approximately 1% of malignant tumors. There are more than 50 subtypes, but pleomorphic sarcoma, liposarcoma, leiomyosarcoma, synovial sarcoma, and malignant peripheral nerve sheath tumor account for 75%. Differentiation between these subtypes is difficult because they often present with a painless enlarging mass, and share many histological and MR imaging features. Nonetheless, subdifferentiation is important because the different subtypes have different prognoses and therapeutic strategies. In this manuscript we discuss the clinical, histological, and MR imaging features of soft tissue sarcomas according to the WHO classification. An overview is provided and differentiating features are discussed that can help to narrow down the differential diagnosis.

Dynamic contrast-enhanced MRI using macromolecular contrast media for monitoring the response to isolated limb perfusion in experimental soft-tissue sarcomas.

The objective of this study was to evaluate the potential of dynamic contrast-enhanced MRI for quantitative characterization of tumor microvessels and to assess the microvascular changes in response to isolated limb perfusion with TNF-alpha and melphalan. Dynamic contrast-enhanced MRI was performed in an experimental cancer model, using a macromolecular contrast medium, albumin-(Gd-DTPA)45. Small fragments of BN 175, a soft-tissue sarcoma, were implanted in 11 brown Norway (BN) rats. Animals were assigned randomly to a control (Haemaccel) or drug-treated group (TNF-alpha/melphalan). MRI was performed at baseline and 24 h after ILP. The transendothelial permeability (K(PS)) and the fractional plasma volume (fPV) were estimated from the kinetic analysis of MR data using a two-compartment bi-directional model. K(PS) and fPV decreased significantly in the drug-treated group compared to baseline (p<0.05). In addition, K(PS) post therapy was significantly lower (p<0.05) in the drug-treated group than in the control group. There was no significant difference in fPV between the drug-treated and the control group after therapy. Tumor microvascular changes in response to isolated limb perfusion can be determined after 24 h by dynamic contrast-enhanced MRI. The data obtained in this experimental model suggest possible applications in the clinical setting, using the appropriate MR contrast agents.

MR imaging of the arthritic rabbit knee joint using albumin-(Gd-DTPA)30 with correlation to histopathology.

The purpose of this study was to demonstrate a technique, in a pilot study, for measuring abnormal capillary permeability in synovial tissue of rabbit arthritic knees using dynamic MRI with a gadolinium-based blood pool agent. Arthritis, simulating rheumatoid arthritis, was induced in knees of 8 rabbits by intra-articular injection of carrageenan (n = 4) or ovalbumin (n = 4). Sequential fat presaturated T1-weighted Spoiled Grass images were obtained before and up to 30 min after intravenous administration of albumin-(Gd-DTPA)30. Estimates of synovial tissue plasma-volume (PV), fractional-leak-rate (FLR), and permeability-surface-area-product (PS) were computed. Histologic correlation was obtained in the corresponding regions. Dynamic MRI showed extravasation of albumin-(Gd-DTPA)30 into hypertrophic synovium in six of the eight arthritic knees. Histologic examination of these six knees showed markedly inflamed synovium. The two knees that did not show abnormal vascular permeability contained non-hypertrophic synovium. None of the rabbits showed abnormal permeability in muscle. MRI derived microvascular characteristics (PV, FLR and PS) correlated positively (r2 = 0.51, 0.97 and 0.86) with the histology. Factors involving the structural and functional microvascular characteristics of synovial tissue can be estimated non-invasively using albumin-(Gd-DTPA)30. This technique may be useful for monitoring disease progression and treatment response in rheumatoid arthritis.

Histologic confirmation of microvascular hyperpermeability to macromolecular MR contrast medium in reperfused myocardial infarction.

A macromolecular MR contrast medium (MMCM) designed to permit histochemical staining and specific tissue localization, albumin-(biotin)10-(Gd-DTPA)25 (Bio-Alb-Gd), was used in a rat model of reperfused myocardial infarction to confirm the presence and distribution of microvascular hyperpermeability. T1-weighted spin-echo images were acquired before and after administration of Bio-Alb-Gd. An avidin-biotin-complex (ABC) stain, specific for the biotinylated MR contrast medium, was used to define the MMCM distribution and to detect any regional change in microvascular permeability related to infarction. Immediately after Bio-Alb-Gd administration, the infarcted region was enhanced, with greatest signal intensity noted at the rim and less at the center. There was a gradual increase in signal intensity of the initially hypointense central region. The steady increase in signal intensity of the central region suggested convection transport of MMCM through the interstitial space and its influx into cellular compartment after leakage from the vascular compartment. Histologic findings confirmed regional microvascular hyperpermeability corresponding to the site of infarction and a predominant rim distribution of the MMCM. Bio-Alb-Gd was identified at high microscopic power in the intravascular, interstitial, and intracellular spaces at the periphery of reperfused infarcted myocardium. Bio-Alb-Gd can be used as an MR contrast medium in reperfused infarcted myocardium to confirm the existence and to localize altered microvascular permeability to macromolecules. Bio-Alb-Gd contrast technique removes all the ambiguity between the distribution of the MR or other imaging contrast agent and the distribution of the substrate for histochemical staining.

Arthritic temporomandibular joint: correlation of macromolecular contrast-enhanced MR imaging parameters and histopathologic findings.

PURPOSE: To assess the utility of macromolecular contrast material-enhanced magnetic resonance (MR) imaging parameters for determining the histopathologic severity of temporomandibular joint (TMJ) arthritis. MATERIALS AND METHODS: Ovalbumin was used to induce arthritis in the TMJs of 10 previously sensitized adult white rabbits. Five rabbits composed the sham-treated control group. Dynamic spin-echo imaging was performed immediately before and for 30 minutes after injection of macromolecular contrast medium. Histologic specimens of TMJ were assessed quantitatively for arthritis. Changes in MR signal intensity were derived from the synovial and subsynovial tissues of the TMJ, and plasma volume (PV) and permeability surface area product (PS) were calculated. These MR parameters and the arthritic scores were compared between sham-treated and antigen-challenged TMJs. The relationships between MR parameters and histopathologic indexes were also determined. RESULTS: Arthritic TMJs showed marked enhancement of the synovial and subsynovial tissues over the imaging period. PS and all histopathologic indexes of arthritis were significantly greater (P < .005) in antigen-challenged than in sham-treated TMJs. PS demonstrated strong positive relationships with all histologic parameters of arthritis, indicating its utility for assessing the severity of joint inflammation. CONCLUSION: Macromolecular contrast-enhanced MR imaging enables quantification of PS and PV in inflamed joints. This technique may provide insights into the pathogenesis of joint inflammation and noninvasive monitoring of disease severity and treatment response in arthritis.

A MRI spatial mapping technique for microvascular permeability and tissue blood volume based on macromolecular contrast agent distribution.

A rapid and automated method for two-dimensional spatial depiction (mapping) of quantitative physiological tissue characteristics derived from contrast enhanced MR imaging was developed and tested in disease models of cancer, inflammation, and myocardial reperfusion injury. Specifically, an established two-compartment kinetic model of unidirectional mass transport was implemented on a pixel-by-pixel basis to generate maps of tissue permeability surface area product (PS) and fractional blood volume (BV) based on dynamic MRI intensity data after administration of albumin-(Gd-DTPA)30, a prototype macromolecular contrast medium (MMCM) designed for blood pool enhancement. Maps of PS and BV in disease models of adenocarcinoma, intramuscular abscess inflammation, and myocardial reperfusion injury clearly depicted zones of increased permeability (up to approximately 500 microl/cc/h--compared to <25 microl/cc/h in normal tissues). As revealed on PS maps, the rank ordering of studied permeability abnormalities was reperfusion injury > inflammation > tumors. A rapid, automated mapping technique derived from dynamic contrast-enhanced MRI data can be used to facilitate the identification and characterization of pathophysiologic abnormalities, specifically relative increases in blood volume and/or microvascular permeability.

Mapping abnormal synovial vascular permeability in temporomandibular joint arthritis in the rabbit using MRI.

An automated method for two-dimensional spatial depiction (mapping) of quantitative physiological tissue characteristics derived from contrast-enhanced MRI was applied to a model of inflammatory disease represented by antigen-induced arthritis of the temporomandibular joint in the rabbit. Specifically, an established two-compartment kinetic model of unidirectional mass transport was implemented on a pixel-by-pixel basis to generate maps of tissue permeability surface area product (PS) and fractional blood volume (BV) based on dynamic MRI intensity data after administration of albumin-(Gd-DTPA)30, a prototype macromolecular contrast medium designed for blood pool enhancement. Maps of PS and BV in a disease model of induced arthritis clearly depicted zones of increased permeability (up to approximately 200 microliters/cc/h-compared to 25 microliters/cc/h in normal tissues).

Mammary carcinoma model: correlation of macromolecular contrast-enhanced MR imaging characterizations of tumor microvasculature and histologic capillary density.

PURPOSE: To determine the relationship between capillary density, a recognized surrogate of tumor angiogenesis, and magnetic resonance (MR) imaging-derived estimates of plasma volume (PV) and microvascular permeability in two mammary carcinoma models. MATERIALS AND METHODS: Dynamic spin-echo imaging was performed by using albumin-(gadolinium-diethylenetriaminepentaacetic acid)34, a prototype blood-pool contrast medium, in 14 rats with a subcutaneously implanted slow- or fast-growing subtype of R3230 mammary carcinoma. Data were fitted to an established two-compartment kinetic model to estimate PV and permeability. RESULTS: MR imaging-derived tumor PVs and permeabilities increased exponentially with increasing capillary density. MR imaging-derived microvascular characteristics correlated strongly with histologic capillary density, with an r2 of .85. CONCLUSION: Contrast medium-enhanced MR imaging may prove useful in estimating angiogenic activity in carcinomas. MR imaging may be superior to histologic assay because it is noninvasive, can be used to "sample" the entire tumor, and reflects both anatomic and physiologic characteristics.

Contrast-enhanced MR imaging assessment of tumor capillary permeability: effect of irradiation on delivery of chemotherapy.

PURPOSE: To assess the effect of x rays on tumor capillary permeability with macromolecular contrast medium (MMCM)-enhanced magnetic resonance (MR) imaging. MATERIALS AND METHODS: One of paired R3230 mammary adenocarcinomas implanted in the flanks of 48 Fischer rats was treated with a single 5- or 15-Gy dose of x rays. After 1 or 3 days, MR imaging in 30 rats was performed unenhanced and enhanced with albumin-(gadolinium diethylenetriaminepentaacetic acid)30 (0.02 mmol gadolinium per kilogram body weight). Signal intensity enhancement was analyzed to estimate fractional blood volume and permeability-surface area product (PS). In 18 irradiated rats, 2.5 mg/kg cisplatin was injected intravenously, and fractional tumor platinum concentrations were measured spectrometrically. RESULTS: MR imaging showed highest capillary permeability 1 day after 15 Gy (PS 110% above control [P<.001]); PS was elevated 57% 1 day after 5 Gy and 63% 3 days after 15 Gy (P<.05). The largest mean tumor platinum fraction occurred 1 day after 15 Gy: 48% versus 20% (control)(P<.05). CONCLUSION: Transient irradiation-induced increase in tumor capillary permeability to cisplatin can be quantified with MMCM-enhanced MR imaging.

Quantification of liver blood volume: comparison of ultra short TI inversion recovery echo planar imaging (ULSTIR-EPI), with dynamic 3D-gradient recalled echo imaging.

An ultra-short TI inversion recovery echo-planar imaging (ULSTIR-EPI) sequence was designed to reduce the influence of water exchange on fractional tissue blood volume (BV) estimation by measurement of T1-changes induced by a gadolinium-based macromolecular contrast medium (MMCM). Fractional liver BV in rats, estimated by ULSTIR-EPI was compared for accuracy to a fast T1-weighted three-dimensional gradient-echo (3D-SPGR, 3D-spoiled gradient recalled acquisition in a steady state) sequence using an in vitro inductively coupled plasma atomic emission spectroscopy (ICP-AES) assay for BV as a standard. Liver images for fractional BV estimation were acquired in eight rats using both ULSTIR-EPI and 3D-SPGR before and after (within 3 to 12 min) intravenous bolus administration of albumin-Gd-DTPA30 (0.05 mmol Gd/kg). Whereas both MR techniques may be useful for fractional tissue BV estimation, ULSTIR-EPI offers certain advantages including greater accuracy, direct T1 maps, and minimization of transendothelial proton exchange effects. 3D-SPGR imaging offers better spatial resolution, current availability on standard clinical MR systems, and acceptable accuracy.