Long-term results of arthroscopic and mini-open repair of small- to medium-size full-thickness rotator cuff tears.

BACKGROUND: This retrospective cohort study evaluated functional outcome and structural integrity after arthroscopic- or mini-open repair of small- to medium-size rotator cuff tears assessed at long-term follow-up. METHODS: All patients operated between 2001 and 2004 were invited to participate. Functional outcome was measured by Constant-Murley Score, Disability of Arm, Shoulder and Hand and Oxford Shoulder Score. Quality of life was assessed with EuroQol Health 5 Dimension. Patient satisfaction was assessed in terms of pain and overall result. Structural integrity of the rotator cuff repair was determined using ultrasound. RESULTS: Of the eligible 62 patients, 44 patients were available for follow-up. After a mean of 11.3 years, 76% of the patients had good to excellent functional outcome on the Constant-Murley Score (median 82, range 29-95). The majority of patients reported good results on both Disability of Arm, Shoulder and Hand and Oxford Shoulder Score (median Disability of Arm, Shoulder and Hand 5.0, range 1.0-54; median Oxford Shoulder Score 19, range 13-39). The quality of life was also good (mean EuroQol Health 5 Dimension utility score 0.88, standard deviation 0.12). Eighty per cent was satisfied with the overall result. Ultrasound examination revealed structural integrity in 76% of all cases. CONCLUSION: This study shows that functional outcome is good and structural integrity is high for the majority of patients 11.3 years after repair of small- to medium-size rotator cuff lesions.

Correction of ankle valgus by hemiepiphysiodesis using the tension band principle in patients with multiple hereditary exostosis.

BACKGROUND: Ankle valgus is a common deformity in patients with multiple hereditary exostoses (MHE) and a potential risk factor for early degenerative arthritis. In children, medial hemiepiphysiodesis of the distal tibia is a relatively simple surgical technique used to correct this deformity. We present here the first results of applying this procedure using the eight-Plate guided growth system (eight-Plate) for growth guidance. METHODS: Between 2006 and 2011 we performed hemiepiphysiodesis of the distal medial tibia in 30 ankles of 18 children with MHE using the eight-Plate. Weight-bearing total leg radiographs were obtained preoperatively, during follow-up and at the time of implant removal or when the distal tibial physis had closed. The lateral distal tibia angle (LDTA) was measured and fibular shortening assessed using the Malhotra classification. To evaluate the effect of hemiepiphysiodesis, we correlated the LDTA with age. RESULTS: The mean age at time of surgery was 12.6 (range 9.5-15.0) years, and the mean preoperative LDTA was 76.9° (range 68.5°-83.5°). During follow-up, the implant was removed in 12 extremities and the physis had closed in 18 extremities. The mean LDTA at the time of implant removal or at closure of the physis was 83.6° (range 76.5°-90.0°). Mean correction of LDTA was 6.9° after a mean follow-up period of 22 (range 3-43) months. During follow-up, no changes in the Malhotra classification were found in any of the patients. Correction of the valgus deformity of the ankle was significantly correlated (r = -0.506) (p = 0.004) with age in all patients. CONCLUSION: Temporary medial hemiepiphyseodesis of the distal tibia seems to be an effective strategy for correcting ankle valgus in children with MHE. Timing of the intervention is, however, of importance. Hemiepiphyseodesis alone has no effect on the Malhotra classification. LEVEL OF EVIDENCE: IV, retrospective review.

Tears of the supraspinatus tendon: assessment with indirect magnetic resonance arthrography in 67 patients with arthroscopic correlation.

BACKGROUND: Magnetic resonance (MR) arthrography is generally regarded as the gold standard for shoulder imaging. As an alternative to direct MR arthrography, the less invasive indirect MR arthrography technique was proposed, offering logistic advantages because fluoroscopic or ultrasonographic guidance for joint injection is not required. PURPOSE: To assess the diagnostic performance of indirect MR arthrography in the diagnosis of full- and partial-thickness supraspinatus tears in a symptomatic population. MATERIAL AND METHODS: Two radiologists with different levels of experience independently and retrospectively interpreted indirect MR (1.5T) arthrograms of the shoulder obtained in 67 symptomatic patients who underwent subsequent arthroscopy. On MR, the supraspinatus tendon was evaluated for full- or partial-thickness tear. With arthroscopy as the standard of reference, sensitivity, specificity, and diagnostic accuracy of indirect MR arthrography in the detection of full- and partial-thickness tears of the supraspinatus tendon was calculated. Kappa (kappa) statistics were used for the assessment of the agreement between arthroscopic and imaging findings and for the assessment of interobserver agreement. RESULTS: For full-thickness tears of the supraspinatus tendon, sensitivities, specificities, and accuracies exceeded 90% for both observers, with excellent interobserver agreement (kappa = 0.910). For partial-thickness tears, sensitivities (38-50%) and accuracies (76-78%) were poor for both reviewers, and interobserver agreement was moderate (kappa = 0.491). Discrepancies between MR diagnosis and arthroscopy were predominantly observed with small partial-thickness tears. CONCLUSION: Indirect MR arthrography is highly accurate in the diagnosis of full-thickness rotator cuff tears. However, the diagnosis of partial-thickness tears with indirect MR arthrography remains faulty, because exact demarcation of degenerative change and partial rupture is difficult. On the basis of the above findings, we do not recommend indirect MR arthrography on patients for whom rotator cuff disease is suspected clinically.

Magnetic resonance imaging after surgery for shoulder instability.

Interpretation of MR imaging of the shoulder after instability repair can be significantly hampered by (susceptibility) artifacts and/or distortion of normal anatomy. Knowledge of the surgical procedures performed including the (ferromagnetic) materials used is important to adjust the imaging protocol, in order to reduce artifacts. MR arthrography is probably the optimal tool for assessment of postoperative capsular-labral structures and rotator cuff defects. More general postoperative complications can be determined or excluded using conventional fast spin echo sequences with or without fat-suppression.

MR arthrography in glenohumeral instability.

The impact of accurate imaging in the work-up of patients with glenohumeral instability is high. Results of imaging may directly influence the surgeon's strategy to perform an arthroscopic or open treatment for (recurrent) instability. Magnetic resonance (MR) imaging, and MR arthrography in particular, is the optimal technique to detect, localize and characterize injuries of the capsular-labrum complex. Besides TI-weighted sequences with fat suppression in axial, oblique sagital and coronal directions, an additional series in abduction and exoroation position is highly advocated. This ABER series optimally depicts abnormalities of the inferior capsular-labrum complex and partial undersurface tears of the spinatus tendons. Knowledge of different anatomical variants that may mimic labral tears and of variants of the classic Bankart lesion are useful in the analysis of shoulder MR arthrograms in patients with glenohumeral instability.

MR arthrography of the rotator cuff.

This article addresses the role of MR arthrography in the evaluation of the rotator cuff, including impingement, tendon degeneration and rotator cuff tears. Additionally, pathologic conditions of the long head of the biceps tendon, and mimickers of rotator cuff pathology are discussed as well. The drawbacks of conventional MR imaging and indirect MR arthrography, compared to the merit of direct MR arthrography are emphasized. The manuscript focusses on the potential clinical consequences of each finding and summarizes which relevant imaging findings should be reported by the radiologist.

Alveolar soft-part sarcoma responding to interferon alpha-2b.

A 23-year-old woman with an alveolar soft-part sarcoma of her calf with pulmonary metastases unresponsive to chemotherapy is described. Interferon (IFN) alpha-2b induced an impressive tumour response still ongoing after IFN treatment had to be stopped because of a psychosis. An explanation of this effect is still speculative.

[Non-traumatic myositis ossificans circumscripta in the teres major muscle]. / Niet-traumatisch ontstane myositis ossificans circumscripta in de M. teres major.

A 49-year-old male presented with a painful progressive swelling in his right axillar region, without further complaints, which had been present for 2 weeks. On radiological examination a peripheral circumferential zone of mineralisation was seen in the right teres major muscle. An incision biopsy specimen showed a lesion of fibroblastic tissue in which areas of osteoid and fragmented lamellar bone tissue, without signs of malignancy. The diagnosis was myositis ossificans circumscripta. This is a rare benign ossifying lesion in skeletal muscles, mostly caused by a trauma and with an average age of occurrence between 20 and 30 years old. It must be differentiated from extra-skeletal osteosarcoma. The pathogenesis is unknown. Because it is a benign and self-limiting disorder, surgical excision is only necessary in case of mechanical hindrance. The patient's swelling partially regressed and he had no further complaints.

Unaltered perception of dyspnoea during treatment with long-acting beta2-agonists.

There is the possibility that during treatment with inhaled long-acting beta2-agonists that a loss of perception of dyspnoea might occur and that the forced expiratory volume in one second (FEV1) might fall precipitously during bronchial provocation. This study investigated these possibilities during methacholine provocation, continued until there was > or =30% fall in FEV1, mimicking a moderate asthma attack. Nineteen asthmatic patients were asked to score their dyspnoea as a Borg score during provocation with methacholine. One hour prior to this provocation, the patients used the last morning dose of 14 days treatment with either formoterol (twice daily 24 microg by Turbuhaler), salmeterol (twice daily 100 microg by Diskhaler) and placebo in a double-blind, randomized, double-dummy, cross-over design. The perception of dyspnoea, expressed as the Borg score divided by the change in FEV1 at > or =30% fall in FEV1, was similar on the three test days at 0.067, 0.076 and 0.074%(-1) after formoterol, salmeterol and placebo treatment, respectively (p=0.16). The slope of the methacholine dose response curve did not differ (p=0.52). In conclusion, no suggestion was found for an abnormal perception of dyspnoea or an exaggerated fall in forced expiratory volume in one second during provocation with methacholine under long-acting beta2-agonist treatment.

Compliance with inhaled glucocorticoids and concomitant use of long-acting beta2-agonists.

We investigated whether treatment with a long-acting beta2-agonist (LAbeta2) is associated with a decrease in patient compliance with regard to inhalation corticosteroids (ICS). Date on prescriptions collected by 15,760 patients suffering from airways disease were provided by 69 Dutch pharmacies. All prescriptions of ICS and LAbeta2 were analysed and divided in four groups by LAbeta2 use during 1997 and 1998. Date from 15,760 patients were available. In the 10,929 patients not treated with LAbeta2, compliance decreased slightly but not significantly. In 3281 patients receiving LAbeta2 compliance also decreased slightly but not significantly. In 404 patients, who used a LAbeta2 in 1997 and discontinued treatment in 1998, the compliance fell significantly (P<0.05). In 1147 patients who started to use a LAbeta2 in 1998, compliance with ICS significantly improved (P<0.05). These results suggest that the regular use of LAbeta2 improves compliance with ICS. Therefore, the concern that compliance with inhaled corticosteroid therapy will decrease under concomitant use of LAbeta2 appear to be unfounded.

Decreased bronchodilating effect of salbutamol in relieving methacholine induced moderate to severe bronchoconstriction during high dose treatment with long acting beta2 agonists.

BACKGROUND: In vitro the long acting beta2 agonist salmeterol can, in contrast to formoterol, behave as a partial agonist and become a partial antagonist to other beta2 agonists. To study this in vivo, the bronchodilating effect of salbutamol was measured during methacholine induced moderate to severe bronchoconstriction in patients receiving maintenance treatment with high dose long acting beta2 agonists. METHODS: A randomised double blind crossover study was performed in 19 asthmatic patients with mean forced expiratory volume in one second (FEV1) of 88.4% predicted and median concentration of methacholine provoking a fall in FEV1 of 20% or more (PC(20)) of 0.62 mg/ml at entry. One hour after the last dose of 2 weeks of treatment with formoterol (24 microg twice daily by Turbuhaler), salmeterol (100 microg twice daily by Diskhaler), or placebo a methacholine provocation test was performed and continued until there was at least a 30% decrease in FEV1. Salbutamol (50 microg) was administered immediately thereafter, followed by ipratropium bromide (40 microg) after a further 30 minutes. Lung function was monitored for 1 hour after provocation. RESULTS: There was a significant bronchodilating and bronchoprotective effect after 2 weeks of active treatment. The dose of methacholine needed to provoke a fall in FEV1 of > or = 30% was higher after pretreatment with formoterol (2.48 mg) than with salmeterol (1.58 mg) or placebo (0.74 mg). The difference between formoterol and salmeterol was statistically significant: 0.7 doubling dose steps (95% CI 0.1 to 1.2, p=0.016). The immediate bronchodilating effect of subsequently administered salbutamol was significantly impaired after pretreatment with both drugs (p<0.0003 for both). Three minutes after inhaling salbutamol the increase in FEV1 relative to the pre-methacholine baseline was 15.8%, 7.3%, and 5.5% for placebo, formoterol and salmeterol, respectively (equivalent to increases of 26%, 14%, and 12%, respectively, from the lowest FEV1 after methacholine). At 30 minutes significant differences remained, but 1 hour after completing the methacholine challenge FEV1 had returned to baseline values in all three treatment groups. CONCLUSION: Formoterol has a greater intrinsic activity than salmeterol as a bronchoprotective agent, indicating that salmeterol is a partial agonist compared with formoterol in contracted human airways in vivo. Irrespective of this, prior long term treatment with both long acting beta2 agonists reduced the bronchodilating effect of an additional single dose of salbutamol equally, indicating that the development of tolerance or high receptor occupancy overshadowed any possible partial antagonistic activity of salmeterol. Patients on regular treatment with long acting beta2 agonists should be made aware that an additional single dose of a short acting beta2 agonist may become less effective.

Contrast-enhanced magnetic resonance imaging of bone marrow.

In the assessment with magnetic resonance (MR) imaging of bone marrow disorders, the use of contrast agents is usually not critical because T1-weighted spin-echo and fat-suppressed sequences (STIR or fat-sat intermediate weighted) are robust and largely available techniques for depiction of neoplastic and non-neoplastic lesions of the bone marrow. This article discusses the characteristics of dynamic contrast-enhanced MR imaging of bone marrow edema, ischemia, and neoplasm. It emphasizes its value in staging and in monitoring of response to chemotherapy of several bone tumors. These fast dynamic contrast-enhanced techniques do not allow differentiation between benign and malignant primary osseous tumors because the biologic behavior rather than the malignant potential of these lesions is reflected.

Malignant progression in multiple enchondromatosis (Ollier's disease): an autopsy-based molecular genetic study.

Multiple enchondromatosis (Ollier's disease) is a nonhereditary disease characterized by multiple central (medullary) cartilaginous bone tumors of unknown pathogenesis. It usually involves the extremities with a unilateral predominance, and sarcomatous transformation may occur. We report an autopsy-based genetic study of a 34-year-old man presenting in early adolescence with multiple enchondromas of the extremities, predominantly left-sided, compatible with Ollier's disease. Twelve years after presentation, malignant transformation to a high grade chondrosarcoma occurred in a tibial enchondroma. The patient died after widespread metastatic disease. Loss of heterozygosity (LOH), in the tibial chondrosarcoma and its metastases, was identified exclusively on chromosome bands 13q14 and 9p21, while being absent in the femoral enchondroma analyzed. Similarly, p53 overexpression was identified immunohistochemically in the tibial chondrosarcoma and its metastases, while being absent in the femoral enchondroma; LOH at 17p13 however, was not demonstrable. It is hypothesized that inactivation of putative tumor suppressor genes at 9p21 and 13q14, and overexpression of p53, identified in the chondrosarcoma and its metastases, but absent in enchondroma, may be related to sarcomatous transformation in Ollier's disease.

Cartilaginous tumors: fast contrast-enhanced MR imaging.

PURPOSE: To differentiate between benign and malignant cartilaginous tumors with fast contrast material-enhanced magnetic resonance (MR) imaging. MATERIALS AND METHODS: In 37 patients, fast contrast-enhanced MR images were obtained in eight enchondromas, 11 osteochondromas, and 18 chondrosarcomas. Start of enhancement-early, within 10 seconds after arterial enhancement; delayed, between 10 seconds and 2 minutes; late, after 5 minutes on spin-echo images-and progression of enhancement were represented with three types of time-signal intensity curves. Findings were correlated with the surgical specimen in 27 cases, curettage material in three cases, and biopsy combined with long-term follow-up findings in seven cases. RESULTS: Start of enhancement and the combination of start and progression of enhancement correlated significantly (P <.001) with benign and malignant tumors. Early enhancement was seen in chondrosarcoma, not seen in enchondroma, and seen in osteochondroma only when growth plates were unfused. The sensitivity was 89%, specificity 84%, positive predictive value 84%, and negative predictive value 89%. Differentiation of malignancy from benignity on the basis of early and exponential enhancement was possible with a sensitivity of 61%, specificity 95%, positive predictive value 92%, and negative predictive value 72%. CONCLUSION: Preliminary results show that in the adult population fast contrast-enhanced MR imaging may assist in differentiation between benign and malignant cartilaginous tumors.

Bone tumors.

We present an overview of the imaging modalities in bone tumors. The imaging strategies of preoperative work-up, monitoring the effect of chemotherapy and the detection of recurrences by long-term follow-up are discussed.

An update of diagnostic strategies using molecular genetic and magnetic resonance imaging techniques for musculoskeletal tumors.

Rheumatologists may be incidentally confronted by bone and soft tissue lesions presenting in and around joints that require early recognition and appropriate referral. The diagnostic and therapeutic management of patients with musculoskeletal tumors is critically dependent on a multidisciplinary approach. Advances, particularly in the fields of histopathology, molecular (cyto)genetics and radiologic imaging techniques, have resulted in significant improvements in reaching a correct (differential) diagnosis, essential for implementing optimal treatment modalities. Magnetic resonance imaging is becoming increasingly important in planning preoperative and postoperative management strategies, and should precede all invasive procedures. Improvements in the fields of immunohistochemistry, together with the realization that certain tumor groups may be associated with specific genetic alterations, has significantly improved diagnostic accuracy. Additionally, the presence of certain genetic alterations within the tumoral genome have been found to be of prognostic value, and the hereditary context recognized for a number of specific bone and soft tissue tumors should be taken into account in the management of a patient with such a neoplasm. It is envisaged that an increasing understanding of the molecular biology and histogenesis of individual musculoskeletal tumor types will lead to tailor-made therapeutic options and consequently prognostic improvements. This update serves to highlight some important recent developments in fundamental and diagnostic aspects of musculoskeletal tumors.

Ultrasound in musculoskeletal tumors with emphasis on its role in tumor follow-up.

Ultrasonography allows visualization of musculoskeletal masses that are not confined to the intraosseous compartment and assists in the determination of the consistency of such masses. Making a specific diagnosis using ultrasonography is hampered by the lack of specificity; however, it may be an indicator in guiding diagnostic needle biopsy, especially in large heterogeneous tumors. Color Doppler flow imaging allows visualization of blood flow within solid soft tissue masses. Probably, CDFI features do not assist in differentiation between malignant and benign tumors; however, it has proved to be a useful tool to monitor regression of tumor neovascularity induced by therapy in patients with musculoskeletal sarcoma. When recurrence of a soft tissue sarcoma is clinically suspected, ultrasonography can be used as the initial imaging technique for evaluation. Ultrasonography can also be used in addition to MR imaging when susceptibility artifacts secondary to orthopedic hardware (including prostheses) prevent evaluation of specific areas.

Musculoskeletal tumors: does fast dynamic contrast-enhanced subtraction MR imaging contribute to the characterization?

PURPOSE: To prospectively analyze the value of fast, dynamic, subtraction magnetic resonance (MR) imaging in the characterization of musculoskeletal tumors. MATERIALS AND METHODS: In 175 consecutive patients with a musculoskeletal mass, dynamic contrast-enhanced subtraction MR imaging was performed after administration of 0.1 mmol per kilogram of body weight gadopentetate dimeglumine or gadoteridol. A turbo gradient-echo technique was used, with a temporal resolution of 1-3 seconds. The interval between arterial and early tumor enhancement, the pattern (peripheral or diffuse) of enhancement, and the progression of tumor enhancement, as visualized on time-signal intensity curves, were assessed. MR enhancement features were related to the histopathologic diagnoses. RESULTS: Differentiation of benign from malignant soft-tissue masses was possible with a sensitivity of 91% and specificity of 72% based on start of enhancement, a sensitivity of 73% and specificity of 97% based on peripheral or diffuse enhancement, and a sensitivity of 86% and specificity of 81% based on progression of enhancement. Benign bone tumors could not be accurately differentiated from malignant bone tumors on the basis of the three defined parameters (sensitivity, 63%-76%; specificity, 50%-76%). CONCLUSION: Dynamic, contract-enhanced, subtraction MR images may be useful to differentiate malignant from benign soft-tissue masses.