Direct magnetic resonance arthrography of the wrist with axial traction: a feasibility study to assess joint cartilage.

PURPOSE: To assess the impact of axial traction during acquisition of direct magnetic resonance (MR) arthrography of the wrist with regard to joint space width and amount of contrast material between the opposing cartilage surfaces. MATERIALS AND METHODS: Fifteen consecutive patients (12 male, mean age 38.1 years) were included in this Institutional Review Board-approved prospective study. Three-compartment wrist MR arthrographies were performed between October and December 2009 on a 3 T unit using a fat-suppressed T1-weighted isotropic high-resolution volumetric interpolated breathhold examination (VIBE) sequence in the coronal plane, with and without axial traction (3 kg). Two radiologists measured radiocarpal (radioscaphoid, radiolunate) and midcarpal (lunocapitate, hamatolunate) joint space widths, with and without traction, and assessed the amount of contrast material between the opposing cartilage surfaces using a three-point scale: 0 = absence, 1 = partial, 2 = complete. RESULTS: With traction, joint space width increased significantly at the radioscaphoid (Δ = 0.78 mm, P < 0.01), radiolunate (Δ = 0.18 mm, P < 0.01), and lunocapitate (Δ = 0.45 mm, P < 0.01) spaces, and both observers detected significantly more contrast material between the cartilage surfaces. At the hamatolunate space, the differences in joint space width (Δ = 0.14 mm, P = 0.54) and amount of contrast material were not significant. CONCLUSION: Direct wrist MR arthrography with axial traction of 3 kg increases joint space width at the radiocarpal and lunocapitate spaces, and prompts better coverage of the articular cartilage by the contrast material.

[Technique and value of direct MR arthrography applying articular distraction]. / Arthro-IRM directe en traction axiale: technique et intérêt.

Direct MR arthrography has a better diagnostic accuracy than MR imaging alone. However, contrast material is not always homogeneously distributed in the articular space. Lesions of cartilage surfaces or intra-articular soft tissues can thus be misdiagnosed. Concomitant application of axial traction during MR arthrography leads to articular distraction. This enables better distribution of contrast material in the joint and better delineation of intra-articular structures. Therefore, this technique improves detection of cartilage lesions. Moreover, the axial stress applied on articular structures may reveal lesions invisible on MR images without traction. Based on our clinical experience, we believe that this relatively unknown technique is promising and should be further developed.

Improving breast cancer education: the case of an evolving multidisciplinary module for undergraduate medical students (Lausanne Medical School, 1993-2008).

Breast cancer is a public health issue in numerous countries. Multidisciplinary collaboration is required for patient care, research, and also education of future physicians. This paper uses Kern's framework for curriculum design to demonstrate how a breast diseases module for undergraduate medical students created in 1993 evolved over 15 years. The main outcomes of program refinements were better integrated course content, the development of electronic course documents, and implementation of computer-aided small group learning. A main future challenge is to further develop efficient instructional strategies in line with well-defined learning needs for undergraduate students.

Outcome of long-axis percutaneous sacroplasty for the treatment of sacral insufficiency fractures.

Our aim was to assess the clinical outcome of patients who were subjected to long-axis sacroplasty for the treatment of sacral insufficiency fractures. Nineteen patients with unilateral (n = 3) or bilateral (n = 16) sacral fractures were involved. Under local anaesthesia, each patient was subjected to CT-guided sacroplasty using the long-axis approach through a single entry point. An average of 6 ml of polymethylmethacrylate (PMMA) was delivered along the path of each sacral fracture. For each individual patient, the Visual Analogue pain Scale (VAS) before sacroplasty and at 1, 4, 24 and 48 weeks after the procedure was obtained. Furthermore, the use of analgesics (narcotic/nonnarcotic) along with the evolution of post-interventional patient mobility before and after sacroplasty was also recorded. The mean pre-procedure VAS was 8±1.9 (range, 2 to 10). This rapidly and significantly (P<0.001) declined in the first week after the procedure (mean 4±1.4; range, 1 to 7) followed by a gradual and significant (P<0.001) decrease along the rest of the follow-up period at 4 weeks (mean 3±1.1; range, 1 to 5), 24 weeks (mean 2.2±1.1; range, 1 to 5) and 48 weeks (mean 1.6±1.1; range, 1 to 5). Eleven (58%) patients were under narcotic analgesia before sacroplasty, whereas 8 (42%) patients were using nonnarcotics. Corresponding values after the procedure were 2/19 (10%; narcotic, one of them was on reserve) and 10/19 (53%; non-narcotic). The remaining 7 (37%) patients did not address post-procedure analgesic use. The evolution of post-interventional mobility was favourable in the study group as they revealed a significant improvement in their mobility point scale (P<0.001). Long-axis percutaneous sacroplasty is a suitable, minimally invasive treatment option for patients who present with sacral insufficiency fractures. More studies with larger patient numbers are needed to explore any unrecognised limitations of this therapeutic approach.

[Imaging in inflammatory spine diseases]. / Imagerie des atteintes inflammatoires rachidiennes.

There is a mean delay of 5 to 8 years between the onset of symptoms and the diagnosis of ankylosing spondylitis. This is due to the fact that radiographic sacroiliitis is delayed. The purpose of an earlier diagnosis is emphasized by the need for better management, the new diagnostic method including magnetic resonance imaging and by the efficacy of anti-TNF therapy. The current criteria are classification but not diagnostic criteria. Their sensitivity is insufficient for an early diagnosis of ankylosing spondylitis. MRI criteria allow to differentiate inflammatory signs from degenerative signs in patients sent for aspecific low back pain. The aims of this article are to illustrate the different stages of the disease from early inflammatory involvement to ankylosis and to discuss the role of imaging in the management of affected patients.

Optimal 3-T MRI for depiction of the finger A2 pulley: comparison between T1-weighted, fat-saturated T2-weighted and gadolinium-enhanced fat-saturated T1-weighted sequences.

OBJECTIVE: To compare three spin-echo sequences, transverse T1-weighted (T1WI), transverse fat-saturated (FS) T2-weighted (T2WI), and transverse gadolinium-enhanced (Gd) FS T1WI, for the visualisation of normal and abnormal finger A2 pulley with magnetic resonance (MR) imaging at 3 tesla (T). MATERIALS AND METHODS: Sixty-three fingers from 21 patients were consecutively investigated. Two musculoskeletal radiologists retrospectively compared all sequences to assess the visibility of normal and abnormal A2 pulleys and the presence of motion or ghost artefacts. RESULTS: Normal and abnormal A2 pulleys were visible in 94% (59/63) and 95% (60/63) on T1WI sequences, in 63% (40/63) and 60% (38/63) on FS T2WI sequences, and in 87% (55/63) and 73% (46/63) on Gd FS T1WI sequences when read by the first and second observer, respectively. Motion and ghost artefacts were higher on FS T2WI sequences. Seven among eight abnormal A2 pulleys were detected, and were best depicted with Gd FS T1WI sequences in 71% (5/7) and 86% (6/7) by the first and the second observer, respectively. CONCLUSION: In 3-T MRI, the comparison between transverse T1WI, FS T2WI, and Gd FS T1WI sequences shows that transverse T1WI allows excellent depiction of the A2 pulley, that FS T2WI suffers from a higher rate of motion and ghost artefacts, and transverse Gd FS T1WI is the best sequence for the depiction of abnormal A2 pulley.

Finger A2 pulley lesions in rock climbers: detection and characterization with magnetic resonance imaging at 3 Tesla--initial results.

OBJECTIVES: To evaluate magnetic resonance imaging (MRI) at 3 T in the diagnosis and characterization of lesions of the finger flexor A2 pulley in patients with clinically suspected A2 pulley lesions. MATERIALS AND METHODS: Eight consecutive patients with clinically suspected lesions of the A2 pulley were included in this retrospective study. 3 T MRI was performed with T1-weighted, T2-weighted fat suppressed, and T1-weighted fat suppressed contrast enhanced sequences. The A2 pulley of all the fingers visible on the images were analyzed and pulley lesions characterized. RESULTS: All asymptomatic pulleys were normal at MRI. In the 8 symptomatic fingers 7 pulleys were abnormal at MRI. With the clinical examination as gold standard, sensitivity, specificity, positive predictive value, and negative predictive value of MRI were 87.5%, 100%, 100%, and 95.2% respectively. Characterization of the different pulley lesion was possible. CONCLUSION: MRI at 3 T allows reliable direct visualization and characterization of traumatic A2 pulley lesions.

A new, easy, fast, and safe method for CT-guided sacroplasty.

Sacral insufficiency fractures constitute clinical challenges because no effective surgical techniques can be applied and only a conservative treatment is currently performed. Sacroplasty is increasingly used to treat sacral insufficiency fractures. A computed tomography (CT)-guided technique concerning the placement of the sacroplasty needles within the sacral wings by using a laser alignment light guidance associated with a CT gantry tilt in a plane parallel to the sacral bone is presented. This method allowed a fast and precise placement of the needle in and along the sacral wings, thus preventing the use of multiple needles to reach the fracture sites.

Articular cartilage lesions of the glenohumeral joint: diagnostic effectiveness of MR arthrography and prevalence in patients with subacromial impingement syndrome.

PURPOSE: To determine the prevalence of articular cartilage lesions in patients with subacromial impingement syndrome and to assess the diagnostic effectiveness of magnetic resonance (MR) arthrography in detecting such cartilage abnormalities. MATERIALS AND METHODS: MR arthrographic images obtained in 52 consecutive patients (mean age, 45.8 years; age range, 17-73 years; 26 male and 26 female patients) were retrospectively evaluated for glenohumeral cartilage lesions. Two experienced musculoskeletal radiologists who were blinded to the arthroscopy report independently analyzed the articular cartilage. Humeral and glenoidal cartilage were assessed separately. The lesions were graded as either subtle or marked. Arthroscopic findings were the standard of reference. Sensitivity, specificity, accuracy, and interobserver agreement were calculated. RESULTS: At arthroscopy, humeral cartilage lesions were found in 15 patients (frequency, 29%). Four lesions were subtle, and 11 were marked. Cartilage lesions of the glenoid were less frequent (eight patients; frequency, 15%): Three were subtle, and five were marked. For reader 1 and reader 2, respectively, sensitivity of MR arthrography for humeral cartilage lesions was 53% and 100%, specificity was 87% and 51%, and accuracy was 77% and 65%; sensitivity for glenoidal cartilage lesions was 75% and 75%, specificity was 66% and 63%, and accuracy was 67% and 65%. Interobserver agreement for the grading of cartilage lesions with MR arthrography was fair (humeral lesions, kappa = 0.20; glenoidal lesions, kappa = 0.27). CONCLUSION: Glenohumeral cartilage lesions are found in up to one third of patients referred for MR arthrography for subacromial impingement syndrome. The performance of MR arthrography in the detection of glenohumeral cartilage lesions is moderate.