Soft tissue tumor imaging in adults: whole-body staging in sarcoma, non-malignant entities requiring special algorithms, pitfalls and special imaging aspects. Guidelines 2024 from the European Society of Musculoskeletal Radiology (ESSR).

OBJECTIVES: The revised European Society of Musculoskeletal Radiology (ESSR) consensus guidelines on soft tissue tumor imaging represent an update of 2015 after technical advancements, further insights into specific entities, and revised World Health Organization (2020) and AJCC (2017) classifications. This second of three papers covers algorithms once histology is confirmed: (1) standardized whole-body staging, (2) special algorithms for non-malignant entities, and (3) multiplicity, genetic tumor syndromes, and pitfalls. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements that had undergone interdisciplinary revision were scored online by the level of agreement (0 to 10) during two iterative rounds, that could result in 'group consensus', 'group agreement', or 'lack of agreement'. RESULTS: The three sections contain 24 statements with comments. Group consensus was reached in 95.8% and group agreement in 4.2%. For whole-body staging, pulmonary MDCT should be performed in all high-grade sarcomas. Whole-body MRI is preferred for staging bone metastasis, with [18F]FDG-PET/CT as an alternative modality in PET-avid tumors. Patients with alveolar soft part sarcoma, clear cell sarcoma, and angiosarcoma should be screened for brain metastases. Special algorithms are recommended for entities such as rhabdomyosarcoma, extraskeletal Ewing sarcoma, myxoid liposarcoma, and neurofibromatosis type 1 associated malignant peripheral nerve sheath tumors. Satisfaction of search should be avoided in potential multiplicity. CONCLUSION: Standardized whole-body staging includes pulmonary MDCT in all high-grade sarcomas; entity-dependent modifications and specific algorithms are recommended for sarcomas and non-malignant soft tissue tumors. CLINICAL RELEVANCE STATEMENT: These updated ESSR soft tissue tumor imaging guidelines aim to provide support in decision-making, helping to avoid common pitfalls, by providing general and entity-specific algorithms, techniques, and reporting recommendations for whole-body staging in sarcoma and non-malignant soft tissue tumors. KEY POINTS: An early, accurate, diagnosis is crucial for the prognosis of patients with soft tissue tumors. These updated guidelines provide best practice expert consensus for standardized imaging algorithms, techniques, and reporting. Standardization can improve the comparability examinations and provide databases for large data analysis.

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where?

OBJECTIVES: Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. MATERIALS AND METHODS: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. RESULTS: Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. CONCLUSION: Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. CLINICAL RELEVANCE: The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. KEY POINTS: • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy.

Meniscal extrusion, cartilage, bone, and ligament lesions associated with medial meniscus posterior root tear gap.

OBJECTIVES: To determine the relationship between the severity of the tear gap resulting from medial meniscus posterior root (MMPR) tear and medial meniscal extrusion, cartilage, bone, and ligament lesions on MRI. METHODS: A total of 133 patients with MMPR tear were retrospectively evaluated. The patients were divided into two groups according to the tear gap width as minor (≤ 4 mm) and widely (4 mm<) displaced. Medial meniscal extrusion and medial compartmental chondromalacia, bone and ligament lesions were analyzed. RESULTS: There were 61 patients (56 women and 5 men) in the minor displaced group (mean age: 56.3 years, range: 29-82 years) and 72 patients (59 women, 13 men) in the widely displaced group (mean age: 53.2 years, range: 20-86 years). There was no significant difference in terms of age and sex (p = 0.31 and p = 0.09, respectively). The mean absolute extrusion was 3.51 mm (range: 1.5-5 mm) in the minor displaced group and 4.52 mm (range: 2.4-7.2 mm) in the widely displaced group (p < 0.001). High-grade medial femoral condylar chondromalacia was more common in the widely displaced group (p = 0.002). Osteophyte, bone marrow edema, and subchondral cyst in the medial compartment, and ligament injury were higher in the widely displaced group, but were not statistically significant (p > 0.05). CONCLUSION: The amount of medial meniscal extrusion and the prevalence of high-grade medial femoral condylar chondromalacia were found to be significantly more in patients with wider tear gap. Determining the amount of tear gap in the evaluation of root ligament tears on MRI is important to predict knee joint internal derangement.

Is It Necessary To Add Soft Tissue Injury to the Classification in Tibial Plateau Fracture Management?

Background A gold standard classification for the treatment of tibial plateau fractures with soft tissue injury has not been established yet.This study aimed to evaluate the usability of a novel modified classification that can provide preoperative information to the surgeon about soft tissue injuries in tibial plateau fractures. Methodology A total of 36 patients with tibial plateau fractures were included in the study. Patients' age, gender, and affected sides were recorded. Injuries to the medial meniscus, lateral meniscus, anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, and lateral collateral ligament were examined with preoperative magnetic resonance imaging. Soft tissue injuries were arranged according to the novel modified classification based on the Schatzker classification. Results The mean age of the study participants was 45 (19-76) years; 72% of the patients were men and 28% were women. Moreover, 44% and 56% of the patients had broken the right and left tibial plateaus, respectively. At least one soft tissue injury was detected in 29 (81%) patients. In 14 (39%) patients, two or more soft tissue injuries were observed. All patients were arranged according to the novel modified classification regarding ligament and meniscus injuries. Conclusions With this novel modified classification system, we think that having better information about the preoperative condition of the soft tissue injuries can change the surgical strategy in patients with tibial plateau fractures.

The coexistence of os trigonum, accessory navicular bone and os peroneum and associated tendon and bone pathologies.

PURPOSE: To determine how often os trigonum is accompanied by accessory navicular and os peroneum. A secondary aim of the study was to investigate the bone and related tendon pathologies that may develop in these three accessory bones. MATERIALS AND METHODS: A total of 110 patients who were evaluated by ankle MRI and were determined with os trigonum between 2009-2015 were included in the study. The frequency was determined of os trigonum together with accessory navicular bone and os peroneum. MR images were also evaluated in respect of bone pathologies and related tendon pathologies of these 3 accessory bones. RESULTS: Of 110 patients determined with os trigonum on MRI, 21 (19%) were also determined with accessory navicular bone and 5 (4.5%) with os peroneum.When bone pathologies were examined, the most frequently seen pathology was bone marrow edema.The most common pathology in the tendons related to the accessory bones was increased amount of synovial fluid within the tendon sheath. In cases with os trigonum, bone changes were observed more frequently than pathologies of the adjacent tendons, in the accessory navicular bone cases, tendon pathologies were observed more than bone changes and in the cases with os peroneum, bone and tendon pathologies were determined at equal rates.There was no significant difference in terms of FHL tendon pathology between patients with and without edema in os trigonum. However, TP tendon was significantly more pathological in patients with edema in accessory navicular bone. CONCLUSION: More than one accessory bone was determined in approximately one in four cases.The most common pathologies determined in these accessory bones was bone marrow edema and increased amount of synovial fluid within the tendon sheath.It is necessary to investigate and report all these findings on MRI as they play an important role in the explanation of clinical findings and treatment planning.

Investigation of ligament, bone, synovial and plica pathologies accompanied by common extensor tendon in patients with lateral overuse syndrome of the elbow using magnetic resonance imaging.

BACKGROUND: Tendinosis in the common extensor tendon and accompanying ligament, bone, and plica abnormalities can be observed on magnetic resonance imaging (MRI). PURPOSE: To determine whether there is a difference between accompanying abnormalities according to the degree of common extensor tendon injury. MATERIAL AND METHODS: Patients who underwent 1.5-T MRI tests with a prediagnosis of lateral overuse syndrome were retrospectively reviewed, and 56 patients who had an injury in the common extensor tendon (CET) were included. The degree of tendon and ligament injury, muscle signal change, bone marrow signal change, presence of joint effusion, and morphological features in the presence of plica were evaluated via MRI examinations of the elbow. RESULTS: Overall, 32, 16, and eight patients had mild, moderate, and severe CET damage, respectively. As the severity of CET damage increased, the presence of joint effusion, and the presence and degree of damage to the lateral ulnar collateral ligament (LUCL) and radial collateral ligament (RCL) increased. The radiohumeral (RH) plica area was significantly larger in the group with mild CET damage. There was no statistically significant correlation between the severity of CET damage and the end of RH plica with a blind-end, coverage of one-third or more of the radius, its signal, thickness, and presence of olecranon fold. CONCLUSION: As the severity of CET injury increases, damage to the LUCL, RCL, and the presence of effusion in the joint increases. RH plica should be evaluated in terms of concomitant pathology in patients with mild CET injuries on MRI.

Variations ignored in routine wrist MRI reports: prevalence of the median nerve anatomical variations and persistent median artery.

BACKGROUND: It is vital to know the anatomical variations of the wrist to avoid iatrogenic injuries during carpal tunnel (CT) surgery. PURPOSE: To determine the anatomical variations of the median nerve (MN) and the prevalence of persistent median artery (PMA) on wrist magnetic resonance imaging (MRI). MATERIAL AND METHODS: A total of 300 wrists evaluated by MRI during 2013-2015 were retrospectively identified. While branching of the MN distal to the CT is accepted as the normal anatomy, proximal to the tunnel and within the tunnel were considered as variations. The prevalence of PMA was also evaluated. The patients were assigned to groups according to age, gender, and wrist side and compared to determine whether there was any significant difference in terms of these variations. All evaluations were assessed with the shared decision of a musculoskeletal radiologist and a radiology resident. RESULTS: Of the 300 wrists, 38 (12.7%) and 34 (11.3%) had a bifid MN proximal to the CT and within the CT, respectively. Only one nerve trifurcation was seen within the CT. The MN exhibited branching distal to the CT in 227 (76%) patients. PMA was observed in 44 (14.7%) patients. Of the 44 PMA cases, 28 (63.6%) also had a coexisting MN variation. There was no significant difference in the prevalence of MN variations and PMA in the subgroups (P > 0.05). CONCLUSION: Nearly one in four patients (24.4%) have MN variations and 14.8% had PMA. Preoperative evaluation of these common anatomical variations with MRI will be protective against postoperative complications of CT surgery.

Clot-based radiomics features predict first pass effect in acute ischemic stroke.

PURPOSE: Our aim was to evaluate the performance of clot-based radiomics features (RFs) for predicting first pass effect (FPE) in patients with acute ischemic stroke (AIS). The secondary purpose was to search for any other variables associated with FPE. MATERIALS AND METHODS: Patients who underwent mechanical thrombectomy (MT) for anterior circulation large vessel stroke in a single center were retrospectively reviewed. Patients were divided into two groups: FPE and non-FPE. Two observers extracted RFs from the clot on pretreatment noncontrast computed tomography (NCCT) images. Demographic, clinical, periprocedural, and RFs were compared between the groups and receiver operating characteristic (ROC) curves were constructed. Logistic regression analysis was used to determine the independent predictors of FPE. RESULTS: Fifty-two patients (27 female, 25 male; mean age 64.50 ± 15.15) who were treated by stent retrievers as the first option were included in the study. FPE was achieved in 25 patients (25/52, 48.1%). Twelve RFs were significantly different between patients with FPE and non-FPE. The long-run low gray-level emphasis (odds ratio = 44.24, p = 0.003) and the zone percentage (odds ratio = 16.88, p = 0.017) were found as independent predictors of FPE. Female sex and a baseline ASPECT score of >8.5 were the other independent variables to predict FPE. The diagnostic accuracy to predict FPE was observed as 83% when using all independent predictors in our predictive model. CONCLUSIONS: Clot-based RFs on NCCT may help to estimate the success of the intended outcome of MT in patients with AIS.

The Incidence of Accessory Ossicles of the Wrist: A Radiographic Study.

Objective Accessory ossicles of the wrist are generally asymptomatic and detected incidentally as radiological findings. These bones are rarely symptomatic but can produce pain in cases of impingement or direct trauma. More frequently, these bones are misinterpreted as avulsion fractures in trauma patients, which may lead to unnecessary immobilization and overtreatment. The aim of this study is to determine the incidence of accessory ossicles of the wrist and also determine if the incidence is related to age, gender, or ongoing wrist pain. Materials and Methods A total of 1146 wrist radiographs were included in the study. All radiographs were analyzed for the presence of 20 different accessory ossicles of the wrist. Patients were also divided into two groups, as with and without accessory ossicle. Two groups were compared in terms of age, gender, and side. Results About 113 accessory ossicles were detected in 111 (9.7%) radiographs. The most common accessory ossicles were os triangulare and os ulnostyloideum, and the least common accessory ossicles were os gruberi and os praetrapezium. Patients who had accessory ossicle had a significantly higher age than those who did not have accessory ossicle. There was no significant difference between the patients with and without accessory ossicle in terms of gender and side. Conclusions The results of this study showed that the most common accessory ossicles in the wrist were os triangulare and os ulnostyloideum, and the incidence of accessory bones increased with age. Clinical Relevance Since accessory ossicles of the wrist can be confused with fractures in trauma patients and are frequently ignored in patients presenting with pain, it is very important to know the incidence and distribution of these ossicles. Therefore, this study is important, in that it provides potentially guiding anatomical data for clinicians in terms of diagnosis and management.

Prevalence, coincidence and distribution patterns of sesamoid bones of the hand / Patrones de prevalencia, coincidencia y distribución de los huesos sesamoideos de la mano

SUMMARY: The aim of this study is to identify the prevalence and distribution patterns of sesamoid bones at the metacarpophalangeal (MCP) and interphalangeal (IP) joints and to determine if there is an association between the distribution patterns and age, gender, and hand side. Patients who had a direct radiograph of the hand obtained between 2019-2020 were retrospectively evaluated. All radiographs were evaluated in terms of the prevalence, coincidence, and distribution patterns of sesamoid bones. Presence of an association between distribution patterns and age, sex and side was also assessed. A total of 1501 hand radiographs were included into the study. There were 12 different patterns of sesamoid bone distribution. The most common distribution pattern was the presence of sesamoid bone at the first MCP joint only (25.8 %). There was a positive correlation between the second and third MCP, second and fifth MCP, second and first IP, third and fourth MCP and fifth MCP and first IP joints. The pattern with a sesamoid bone at the first MCP joint only was more prevalent among males, whereas the pattern involving coincidence of sesamoid bones at the first, second, fifth MCP and first IP joints was more prevalent among females (p<0.001, p=0.031). A positive correlation was observed between age and the number of MCP joints with sesamoid bones (p<0.001). The number of MCP joints with sesamoid bones was found to be higher in females (p<0.001). This study is important in that it provided anatomical data that can be guiding for clinicians in terms of diagnosis and management of hand disorders.

RESUMEN: El objetivo de este estudio fue identificar la prevalencia y los patrones de distribución de los huesos sesamoideos en las articulaciones metacarpofalángicas (MCF) e interfalángicas (IF) y determinar si existe una asociación entre los patrones de distribución y la edad, el sexo y el lado de la mano; fueron evaluadas retrospectivamente radiografías de la mano obtenidas en 2019- 2020. Todas las radiografías se evaluaron en términos de prevalencia, coincidencia y patrones de distribución de los huesos sesamoideos. También se evaluó la presencia de una asociación entre los patrones de distribución y la edad, el sexo y el lado. Se incluyeron en el estudio un total de 1501 radiografías de mano. Se observaron 12 patrones diferentes de distribución de los huesos sesamoideos. El patrón de distribución más común fue la presencia de hueso sesamoideo solo en la primera articulación MCF (25,8 %). Hubo una correlación positiva entre la segunda y la tercera MCF, la segunda y la quinta MCP, la segunda y la primera IF, la tercera y cuarta MCF y la quinta MCF y las primeras articulaciones IF. El patrón con un hueso sesamoideo en la primera articulación MCF fue más prevalente entre los hombres, mientras que el patrón de coincidencia de los huesos sesamoideos en la primera, segunda, quinta articulación MCF y la primera articulación IF fue más prevalente entre las mujeres (p <0.001, p = 0,031). Se observó una correlación positiva entre la edad y el número de articulaciones MCF con huesos sesamoideos (p <0,001). El número de articulaciones MCF con huesos sesamoideos era mayor en las mujeres (p <0,001). Este estudio es importante debido a que proporcionó datos anatómicos que pueden ser una guía para los médicos en el diagnóstico y tratamiento de los trastornos de la mano.

The relationship between patellar tilt and quadriceps patellar tendon angle with anatomical variations and pathologies of the knee joint.

PURPOSE: To investigate the association between the knee joint anatomical variations and pathologies, and to describe the quadriceps patellar tendon angle (QPA). METHODS: MRIs of 406 cases with a lateral patellar tilt angle (LPT)>5° and a control group of 40 cases with an LPT<5° were retrospectively evaluated. QPA, LPT, trochlear sulcus angle (TSA), tibial tubercle-trochlear groove distance (TT-TG), Insall-Salvati index (ISI), patellar tendon length (PTL), patellar height (PH), lateral trochlear inclination (LTI), trochlear facet asymmetry ratio (TFA) and trochlear depth (TD) were measured. Presence of fat-pad oedema, patellar and trochlear chondromalacia, patellar and quadriceps tendinosis and effusion were evaluated. RESULTS: The medians of TSA, PTL, ISI and TT-TG were significantly higher; LTI, TFA and TD were significantly lower in the patient group. The prevalence of SL-Hoffa, non-SL-Hoffa, suprapatellar and prefemoral fat-pad oedema, effusion and chondromalacia were significantly higher in the patient group. LPT was found to be positively correlated with TSA and TT-TG, and negatively correlated with LTI and TD. Cases with trochlear dysplasia, patellar chondromalacia and quadriceps tendinosis had significantly higher LPT. There was a positive correlation between QPA and TSA and a negative correlation between QPA and LTI. Cases with trochlear dysplasia, non-SL-Hoffa oedema, prefemoral fat-pad oedema and quadriceps tendinosis had significantly higher QPA. We found 10°

Histopathological and Tumor Characteristics Associated with False Negative Axillary Ultrasonography Results in Breast Cancer.

AIMS: As the false-negative rates of axillary ultrasonography (AUS) (21%-48%) are not optimal, the demand for axillary surgery remains even if AUS is negative. The aim of this study is to determine the histopathological and tumor characteristics associated with false-negative AUS results. MATERIALS AND METHODS: Patients with normal AUS were divided into two groups as true-negative and false-negative according to the histopathology results of axillary lymph nodes. Two groups were compared in terms of age, histological grade of the primary tumor, histological size of the primary tumor, histological type, lymphovascular invasion (LVI), and ultrasonography BI-RADS classification of the primary tumor. The number of metastatic lymph nodes, size of the largest metastatic lymph node and the number of micrometastatic lymph nodes were also noted in the false-negative group. RESULTS: There were 152 patients with normal preoperative AUS in the study group. The false-negative AUS rate was 20.4%. The incidence of invasive lobular carcinoma (ILC) and the mean tumor size was significantly greater in the false-negative group. Micrometastasis was present in 3 patients (3/31, 9.6%), the mean of the largest metastatic lymph nodes was 12.5 mm, the mean total number of malignant lymph nodes was 1.9 in the false-negative group. In 25/31 (80.6%) of the patients, there were less than or equal to 2 metastatic lymph nodes. The presence of LVI was higher in the false-negative group. There was no significant difference between the groups in terms of the other parameters. CONCLUSION: Before stating that the axilla is normal on ultrasonography, a careful evaluation should be made in patients with a mass >2 cm in size and/ or ILC diagnosis.

Investigation of the Relationship between Anterior Knee Pain and Chondromalacia Patellae and Patellofemoral Malalignment.

OBJECTIVE: The study aimed to investigate whether there is any association of anterior knee pain and knee function with chondromalacia stage and patellofemoral alignment in patients with anterior knee pain for over a month and with chondromalacia patellae (CMP) detected by magnetic resonance imaging (MRI). MATERIALS AND METHODS: We reviewed the medical records of 38 patients who underwent a knee MRI examination and were diagnosed with chondromalacia based on the MRI. Knee MRI images were evaluated by a radiologist for chondromalacia staging. Patients were divided into two groups as early stage (stage 1-2) and advanced stage (stage 3-4) chondromalacia. Patients' demographical data (age, sex, and occupation), clinical features, physical examination findings and patellofemoral pain severity scale, kujala patellofemoral scoring system, and functional index questionnaire scores were obtained from their medical records. Trochlear sulcus angle, sulcus depth, lateral patellofemoral angle, patellar translation, and Insall-Salvati index were measured using the MRI images. RESULTS: The mean patient age was higher in the advanced stage CMP group compared to the early stage CMP group (p=0.038). There was no statistically significant difference regarding other demographical data (p>0.05). MRI measurement parameters did not show difference between the groups (p>0.05). Patients in the advanced stage CMP group had higher patellofemoral pain severity score, lower kujala patellofemoral score, and lower functional index questionnaire score compared to the early stage CMP group. The differences were statistically significant (p=0.008, p=0.012, and p=0.026, respectively). CONCLUSION: As chondromalacia stage advances, the symptom severity worsens and knee functions decline; however, MRI measurements do not show difference between early and advanced stage CMP patients.

The association of patellar maltracking with infrapatellar fat pad edema and chondromalacia patella: A quantitative morphological magnetic resonance imaging analysis.

OBJECTIVES: This study aims to investigate the relationship of patellofemoral joint morphology with infrapatellar fat pad edema and chondromalacia patella (CP) using patellar maltracking parameters on magnetic resonance imaging (MRI). PATIENTS AND METHODS: Between January 2010 and January 2013, 50 patients with edema in the superolateral portion of the infrapatellar fat pad (the study group) and control group (n=50) with a normal infrapatellar fat pad were identified on MRI to compare with regard to five patellar maltracking parameters retrospectively. These parameters were trochlear depth, the trochlear sulcus angle (TSA), patellar translation, the lateral patellofemoral angle (PFA), and the Insall-Salvati ratio. The relationship between patellar maltracking and the CP was also evaluated using the same parameters. RESULTS: In the study group, the Insall-Salvati index and TSA were significantly higher (p=0.001), and the trochlear depth and PFA were low (p=0.001, p=0.01), while patellar translation showed no difference (p=0.957). In the CP group, the Insall-Salvati index and TSA were significantly high (p=0.001), the trochlear depth was low (p=0.001). No statistically significant difference was found in PFA and patellar translation (p=0.292, p=0.446). CONCLUSION: Our study results suggest that edema in the superolateral portion of infrapatellar fat pad and CP are associated with patellar maltracking.

The effect of ulnar variance on scapholunate and capitolunate angles.

Background Ulnar variance (UV), which is measured using anteroposterior (AP) X-rays, is associated with the development of multiple wrist pathologies. The scapholunate angle (SLA) and capitolunate angle (CLA) are measured using lateral X-rays, and these can be used in the diagnosis of intercalated segmental instability. Purpose To determine the effect of UV on SLA and CLA. Material and Methods A total of 140 patients (73 women, 67 men; mean age, 37.8 ± 14.6 years; 95% confidence interval [CI], 35.4-40.3) were included in the study. Participants were excluded if they presented with fractures or malunions, any arthritic conditions, avascular necrosis, congenital deformities, or bone and soft tissue tumors. UV, SLA, and CLA were measured using AP and lateral wrist X-rays. Results Patients were grouped as positive, neutral, and negative UV. There was no statistically significant difference in mean ages, sex, and sides (left or right) between the UV groups ( P > 0.05). In addition, there was no statistically significant difference in the mean values of SLA and CLA between the UV groups ( P > 0.05). UV showed no statistically significant association with SLA and CLA (r = -0.064; P = 0.455, and r = 0.059; P = 0.485, respectively). However, there was a statistically significant association between SLA and CLA (r = -0.482; P < 0.001). Conclusion There is higher prevalence of neutral UV and no correlation between UV with respect to age and sex of patients in the local Turkish population. SLA and CLA are not affected by UV. There is a negative correlation between SLA and CLA.

Wassel's Type V Polydactyly with Plain Radiographic and CT Findings.

Duplication of the thumb is the most common polydactyly of the hand. Wassel's classification is frequently used to classify the polydactyly of the hand. His classification was based on the level of duplication and the number of bones in the thumb, and has seven groups (Types I-VII) according to the level of the bifurcation, except for his Type VII. The most common type is the bifurcation at the metacarpophalangeal joint (Type IV). In this paper, we report a very rare case of Type V thumb polydactyly in a 42-year-old man, who presented with swan neck deformity of the radial thumb and discuss the plain radiography and computed tomography (CT) findings. Kumar recently reported plain radiography findings in a case of bifid first metacarpal in a 13-year-old girl, who presented with swan neck deformity of the left thumb. To our knowledge, our case is the second presented case that has a swan neck deformity with bifid metacarpal.

The anatomic variations of the posterior talofibular ligament associated with os trigonum and pathologies of related structures.

PURPOSE: The aim of this study is to investigate the detailed anatomy of the posterior talofibular ligament (PTFL) on MR images in patients with os trigonum. We also evaluated the pathological conditions of the PTFL, anterior talofibular ligament (ATFL), flexor hallucis longus (FHL) tendon, talus and os trigonum. METHODS: Ankle MRIs of 70 patients with os trigonum (study group) and 70 patients without it (control group) were reviewed for the anatomy of the anterior and posterior fibers of PTFL. The prevalence of PTFL and ATFL pathologies was also compared between two groups. Additionally FHL tenosynovitis and osseous pathologies were evaluated. RESULTS: The posterior fibers inserted into the lateral tubercule of the posterior process of the talus in the control group whereas if an os trigonum was present, the posterior fibers of PTFL were inserted only into the os trigonum. The origins of anterior and posterior fibers were the medial surface of the lateral malleolus and the insertion of the anterior fibers was lateral surface of the talus posterior to the lateral malleolar facet in both groups. There was a significant association between an abnormal PTFL, ATFL and the presence of os trigonum. FHL tenosynovitis was higher in the study group but it did not meet the statistical significance. The most common pathology of the talus and os trigonum was subchondral edema along the synchondrosis. CONCLUSIONS: In patients with os trigonum, the posterior fibers of the PTFL were inserted herein. In the case of an os trigonum signal alterations of ligaments were more common, which may reflect chronic instability.

Subacromial osteochondroma: A rare cause of impingement syndrome.

INTRODUCTION: Subacromial impingement syndrome is one of the most common disorders of shoulder. Scapula is a very rare site for osteochondromas, and osteochondromas arising under the acromion cause impingement syndrome. PRESENTATION OF CASE: We presented 34-year old female patient with subacromial impingement syndrome secondary to osteochondroma. She had received conservative treatment several times in other clinics. The osteochondroma causing impingement was not diagnosed. Physical examination of the right shoulder revealed 90° flexion, 70° abduction, 20° external rotation and internal rotation to sacrum. X-ray, CT and MRI of the shoulder was obtained. Osteochondroma of the acromion (35×33×25mm) causing impingement was detected. The osteochondroma of acromion compressed, displaced and ruptured the supraspinatus tendon. Also an osseous prominence of glenoid was detected during shoulder arthroscopy, and it was removed arthroscopically. The giant osteochondroma of acromion could not remove arthroscopically due to the size of the lesion, and it was removed totally through a mini open approach. Histopathological examination confirmed the diagnosis of osteochondroma. DISCUSSION: Scapular, clavicular and humeral osteochondromas cause impingement syndrome. Osteochondroma should be treated with total excision. Recurrences can be seen due to insufficient removal of osteochondromas. We think that, total excision is important to prevent recurrence. Subacromial osteochondroma is a very rare cause of impingement syndrome, and if it isn't diagnosed early it limits shoulder movements, causes severe shoulder impingement and rotator cuff tear. CONCLUSION: The diagnosis of subacromial osteochondroma should be considered in any patient with shoulder impingement syndrome and good functional results can be expected following total excision.