MR imaging of normal extrinsic wrist ligaments using thin slices with clinical and surgical correlation

Eighty-nine MR examinations of the wrist were retrospectively analyzed. MRI results were compared with clinical findings and/or arthroscopy. Thin proton density and T2 weighted sequences and 3D DESS weighted sequences were applied on a 1.5 T scanner. On the palmar side three radiocarpal ligaments are recognized including the radioscaphocapitate, radiolunotriquetral, radioscapholunate, and midcarpal triquetroscaphoidal ligaments. Ulnocarpal ligaments include the ulnolunate ligament and the ulnotriquetral ligament. On the dorsal side three ligaments are recognized: the dorsal radiolunotriquetral, and the midcarpal triquetroscaphoidal and triquetro-trapezoido-trapezial. The collateral ligaments include the radial and ulnar collateral ligament. MR is a valuable technique in the assessment of the extrinsic and midcarpal ligaments. Depiction of the extrinsic ligaments can best be accomplished with coronal 3D DESS sequences and sagittal and transverse proton density and T2 weighted sequences with thin slices.     

Distribution of primary osteoarthritis in the ulnar aspect of the wrist and the factors that are correlated with ulnar wrist osteoarthritis: a cross-sectional study

Objective

The purpose of this cross-sectional study was to identify the distribution of primary osteoarthritis (OA) in the ulnar aspect of the wrist, and analyze the factors correlated with OA at this site.

Materials and methods

A total of 1,128 cases of skeletally mature Japanese patients were collected over a 3-year period. We analyzed the posteroanterior and lateral wrist radiographs of these patients for the presence of primary OA in the ulnar aspect of the wrist, including the distal radioulnar (DRUJ), radiolunate, ulnolunate, lunotriquetral, triquetrohamate, lunohamate, and lunocapitate joints. All joints were examined for the frequency of primary OA. Multivariate logistic regression was used to investigate the factors correlated with the presence of degenerative arthritis in the ulnar aspect of the wrist joint.

Results

Primary OA of the ulnar wrist was identified in 145 out of 1,128 cases (12.8 %). Degenerative changes were most frequently identified in the DRUJ (12.3 %), followed by the ulnolunate joint (8.1 %). Variations in radial inclination (RI), carpal height ratio (CHR), and ulnar variance (UV) correlated with OA of the ulnar aspect of the wrist, with variations in UV showing the highest correlation.

Conclusion

Primary OA of the ulnar wrist was most frequent in the DRUJ and second most frequent in the ulnolunate joint. UV correlated most with OA in the ulnar aspect of the wrist.     

Aiming for a shorter rheumatoid arthritis MRI protocol: can contrast-enhanced MRI replace T2 for the detection of bone marrow oedema?

Purpose

To determine whether T1 post-gadolinium chelate images (T1Gd) can replace T2-weighted images (T2) for evaluating bone marrow oedema (BME), thereby allowing a shorter magnetic resonance imaging (MRI) protocol in rheumatoid arthritis (RA).

Material and methods

In 179 early arthritis patients and 43 advanced RA patients, wrist and metacarpophalangeal joints were examined on a 1.5-T extremity MRI system with a standard protocol (coronal T1, T2 fat-saturated and coronal and axial T1 fat-saturated after Gd). BME was scored according to OMERACT RAMRIS by two observers with and without T2 images available. Agreement was assessed using intraclass correlation coefficients (ICCs) for semi-quantitative scores and test characteristics with T2 images as reference.

Results

Agreement between scores based on T2 and T1Gd images was excellent ICC (0.80–0.99). At bone level, sensitivity and specificity of BME on T1Gd compared to T2 were high for both patient groups and both readers (all ≥80 %).

Conclusion

T1Gd and T2 images are equally suitable for evaluating BME. Because contrast is usually administered to assess (teno)synovitis, a short MRI protocol of T1 and T1Gd is sufficient in RA.

Key Points

? Bone marrow oedema scores are equal on T2 and T1-Gd-chelate enhanced sequences. ? Agreement between scores based on T2 and T1-Gd-chelate images was excellent. ? Sensitivity and specificity for presence of bone marrow oedema were high. ? A short protocol without T2 images suffices in rheumatoid arthritis patients.     

Extrinsic carpal ligaments: normal MR arthrographic appearance in cadavers

PURPOSE: To describe the normal magnetic resonance (MR) arthrographic anatomy of the major carpal ligaments (excluding scapholunate and lunotriquetral ligaments) and their osseous attachments by using standard imaging planes. MATERIALS AND METHODS: MR images of 22 wrists derived from fresh human cadaveric hands were obtained after tricompartmental arthrography. The MR arthrographic appearance of the carpal ligaments and their bone attachments were analyzed and correlated to those seen on anatomic sections. Two readers determined in consensus which was the best plane to observe the course and attachment sites for each ligament. They further analyzed the size and sites of attachment of these ligaments in two orthogonal planes chosen for optimal viewing. RESULTS: Each ligament was well seen as a hypointense linear structure with MR arthrography. The radioscaphocapitate, radiolunotriquetral, radioscapholunate, dorsal radiotriquetral, palmar scaphotriquetral, and dorsal scaphotriquetral ligaments were best evaluated in the transverse plane. The palmar and dorsal ulnotriquetral and ulnolunate ligaments were best visualized in the sagittal plane. The radial collateral ligament was best analyzed in the coronal plane. The attachment sites of all ligaments were best analyzed either in the transverse or sagittal planes. CONCLUSION: MR arthrography allows visualization of the carpal ligaments. Detailed knowledge of the normal appearance of these ligaments can serve as a baseline for future studies in which MR arthrography is used to characterize wrist instability.     

Cone-beam computed tomography arthrography: an innovative modality for the evaluation of wrist ligament and cartilage injuries

Purpose

Cone-beam computed tomography (CBCT) has become an important modality in dento-facial imaging but remains poorly used in the exploration of the musculoskeletal system. The purpose of this study was to prospectively evaluate the performance and radiation exposure of CBCT arthrography in the evaluation of ligament and cartilage injuries in cadaveric wrists, with gross pathology findings as the standard of reference.

Materials and methods

Conventional arthrography was performed under fluoroscopic guidance on 10 cadaveric wrists, followed by MDCT acquisition and CBCT acquisition. CBCT arthrography and MDCT arthrography images were independently analyzed by two musculoskeletal radiologists working independently and then in consensus. The following items were observed: scapholunate and lunotriquetral ligaments, triangular fibrocartilage complex (TFCC) (tear, integrity), and proximal carpal row cartilage (chondral tears). Wrists were dissected and served as the standard of reference for comparisons. Interobserver agreement, sensitivity, specificity, and accuracy were determined. Radiation dose (CTDI) of both modalities was recorded.

Results

CBCT arthrography provides equivalent results to MDCT arthrography in the evaluation of ligaments and cartilage with sensitivity and specificity between 82 and 100%, and interobserver agreement between 0.83 and 0.97. However, radiation dose was significantly lower (p?Conclusion CBCT arthrography appears to be an innovative alternative to MDCT arthrography of the wrist as it allows an accurate and low radiation dose evaluation of ligaments and cartilage.     

Relationship between stress ankle radiographs and injured ligaments on MRI

Objective

This study was performed to investigate the relationship between the injured lateral ankle ligaments on MRI and stress ankle radiographs.

Materials and methods

Two hundred and twenty-nine consecutive patients (mean age 35.5 years, SD 14.6 years; 136 males and 93 females) that underwent ankle stress radiographs and MRI for lateral ankle instability were included. Tibiotalar tilt angle and anterior translation of talus were measured on stress ankle radiographs. Degree of lateral ligaments (anterior talofibular, calcaneofibular, and posterior talofibular) and deltoid ligament injuries were evaluated and scored as intact (0), partial injury (1), and complete injury (2) on MR images. Effusion of ankle joint was also recorded. The effects of gender, age, injuries of ligaments, and ankle joint effusion on stress radiographs were statistically analyzed.

Results

Gender (p?=?0.010), age (p?=?0.020), and anterior talofibular ligament (ATFL) injury (p?<?0.001) were the factors significantly affecting tibiotalar tilt angle. Posterior talofibular ligament (PTFL) injury (p?=?0.014) was found to be the only significant factor affecting the anterior translation on the anterior drawer radiographs.

Conclusions

ATFL injury and PTFL injury on MRI significantly affected tibiotalar tilt angle and anterior drawer on stress radiographs. Other factors, such as age and gender, need to be considered in evaluating radiographic lateral ankle instability.     

Extensor tendon rupture and three-dimensional computed tomography imaging of the rheumatoid wrist

Purpose

Extensor tendon rupture on the dorsum of the wrist is commonly seen in patients with rheumatoid arthritis (RA). The diagnosis of tendon rupture is usually straightforward, but it is sometimes difficult in the hand with complex deformity. The purposes of this study were to investigate the reliability of three-dimensional computed tomography (3DCT) imaging of extensor tendons in the rheumatoid wrist and in the normal wrist and to clarify the validity of its clinical application to the diagnosis of tendon rupture in the rheumatoid wrist.

Methods

Preoperative 3DCT images of 48 wrists of 45 patients with RA and 3DCT images of 38 wrists of 38 healthy volunteers were reviewed retrospectively by six orthopaedic surgeons who were unaware of all other study data. Extensor tendon rupture was verified by operation on 20 rheumatoid wrists.

Results

Regarding interobserver and intra-observer reliabilities of 3DCT imaging of the extensor tendons, agreement with respect to tendon rupture in this study group was high, and Cohen's kappa (κ) coefficient was variable, depending on the individual tendon. Positive predictive value (PPV) of tendon rupture in the extensor digiti minimi (EDM), extensor digitorum communis (EDC) V and IV and extensor pollicis longs (EPL) tendons was more than 60%, but those for the other extensor tendons were less than 50%. Negative predictive value (NPV) was more than 96% in all extensor tendons, in both rheumatoid and normal wrists.

Conclusions

Extensor tendons in normal and rheumatoid wrists were well depicted by 3DCT imaging. In the rheumatoid wrists, extensors of the ring and little fingers and the thumb were depicted more accurately than those to the other fingers. 3DCT imaging was clinically applicable to wrists for which it was difficult to diagnose by physical examination a definite cause for the loss of extension of the fingers.     

Characterisation of hand small joints arthropathy using high-resolution MRI—Limited discrimination between osteoarthritis and psoriatic arthritis

Objective

To test the hypothesis that microanatomical differences in joint disease localisation could be exploited using high-resolution MRI to better differentiate among rheumatoid arthritis (RA), spondyloarthritis/psoriatic arthritis (SpA/PsA) and osteoarthritis (OA) in clinical practice.

Methods

Sixty-nine patients with suspected inflammatory joint disease of the hand or feet underwent high-resolution MRI using a small loop coil. Images were scored blinded to the clinical status. Various joint changes like periostitis, osteitis, erosions, enthesitis and synovitis were recorded. The image-based diagnosis was compared with the clinical diagnosis.

Results

In 59.4 % of the patients the clinical diagnosis was confirmed on image analysis. This was high for OA (80 %), moderately good for RA (67 %) but only 50 % for SpA/PsA. The major difficulty was to distinguish OA from SpA/PsA where common imaging findings are evident including periostitis (SpA/PsA 45 %, OA 40 % compared with RA 0 %; P?=?0.015). Likewise, osteitis was frequently detected in SpA/PsA (79 %) and OA (80 %) and less frequently in RA (42 %) (P?=?0.014).

Conclusion

Characterisation of inflammatory disorders of small joints merely using high-resolution MRI remains challenging especially in the differentiation between OA and PsA. These findings are likely explained by common microanatomical similarities in disease expression rather than limitations of imaging techniques.

Key Points

? High-resolution MRI is increasingly used to investigate joint disease. ? Osteitis and periostitis occur in psoriatic and osteoarthritis (but not rheumatoid arthritis). ? In severely affected patients the amount of synovitis and erosions is similar.     

Ultrasonographic evaluation of normal extrinsic and intrinsic carpal ligaments: preliminary experience

Objective To determine normal anatomy of extrinsic and intrinsic carpal ligaments at ultrasonography (US).Design and volunteers In the first part of the study, two musculoskeletal radiologists retrospectively reviewed in consensus the photographs of anatomic sections and dissections derived from 20 cadaveric wrists. This cadaveric study gave the two readers the opportunity to learn the anatomy and orientation of the various extrinsic and intrinsic carpal ligaments and, thus, to develop a US protocol to facilitate the recognition of each carpal ligament. In the second part of the study, these two radiologists prospectively and independently evaluated the visibility of extrinsic and intrinsic carpal ligaments in 30 wrists of volunteers, using the same US protocol.Results With regard to extrinsic carpal ligaments, the radioscaphocapitate ligament (partially visible, 38%; completely visible, 62%), the radiolunotriquetral ligament (partially visible, 27%; completely visible, 73%), the palmar ulnotriquetral ligament (partially visible, 12%; completely visible, 88%), and the dorsal radiotriquetral ligament (partially visible, 7%; completely visible, 93%) were visualized at US. The dorsal ulnotriquetral ligament (partially visible, 21%; completely visible, 74%), the ulnolunate ligament (partially visible, 5%; completely visible, 70%), and the radial collateral ligament (partially visible, 18%; completely visible, 12%) were more difficult to recognize. The radioscapholunate ligament was never seen. With regard to intrinsic carpal ligaments, the dorsal (partially visible, 11%; completely visible, 89%) and palmar (partially visible, 38%; completely visible, 62%) scaphotriquetral ligaments as well as the dorsal scapholunate ligament (partially visible, 3%; completely visible, 97%) were visualized at US. The dorsal lunotriquetral ligament (partially visible, 39%; completely visible, 61%) and the palmar scapholunate ligaments (partially visible, 12%; completely visible, 81%) were more difficult to recognize.Conclusion US may be helpful in identifying the major extrinsic and intrinsic carpal ligaments.     

The shiny corner of the knee: a sign of meniscal osteochondral unit dysfunction

Objective

The purpose of this retrospective study is to describe the MRI findings of the “shiny corner” of the knee (bone marrow lesions at the meniscal-covered portions of the tibial plateau) and to determine its association with compromise of the medial meniscal-osteochondral unit.

Materials and methods

A retrospective review of 200 knee MRI exams was performed and images were evaluated in consensus by two musculoskeletal radiologists. Presence and location of a shiny-corner lesion was recorded, which was defined as a focal, peripheral hyperintense lesion on fluid-sensitive images at the superior portion of the medial tibial plateau. Meniscal and root ligament abnormalities were recorded, including tearing, degeneration, and extrusion.

Results

Sixty exams demonstrated a shiny-corner lesion. Shiny corners involved the medial rim of the medial tibial plateau in 50 cases, only involved the posterior rim in seven cases, and only involved the anterior rim in two cases. Patients with shiny corners were older than patients without shiny corners (mean, 53 years vs. 44 years, p?=?0.01). The shiny-corner sign was associated with tears of the medial meniscus, root ligament, and meniscal extrusion (p?Conclusions Shiny-corner lesions of the knee are associated with tears of the menisci and root ligaments. This observation supports the concept that the menisci protect the underlying covered portions of the tibial plateau.     

Digital X-ray radiogrammetry of hand or wrist radiographs can predict hip fracture risk—a study in 5,420 women and 2,837 men

Objectives

To assess whether digital X-ray radiogrammetry (DXR) analysis of standard clinical hand or wrist radiographs obtained at emergency hospitals can predict hip fracture risk.

Methods

A total of 45,538 radiographs depicting the left hand were gathered from three emergency hospitals in Stockholm, Sweden. Radiographs with insufficiently included metacarpal bone, fractures in measurement regions, foreign material or unacceptable positioning were manually excluded. A total of 18,824 radiographs from 15,072 patients were analysed with DXR, yielding a calculated BMD equivalent (DXR-BMD). Patients were matched with the national death and inpatient registers. Inclusion criteria were age ≥ 40 years, no prior hip fracture and observation time > 7 days. Hip fractures were identified via ICD-10 codes. Age-adjusted hazard ratio per standard deviation (HR/SD) was calculated using Cox regression.

Results

8,257 patients (65.6 % female, 34.4 % male) met the inclusion criteria. One hundred twenty-two patients suffered a hip fracture after their radiograph. The fracture group had a significantly lower DXR-BMD than the non-fracture group when adjusted for age. The HR/SD for hip fracture was 2.52 and 2.08 in women and men respectively. The area under the curve was 0.89 in women and 0.84 in men.

Conclusions

DXR analysis of wrist and hand radiographs obtained at emergency hospitals predicts hip fracture risk in women and men.

Key Points

? Digital X-ray radiogrammetry of emergency hand/wrist radiographs predicts hip fracture risk. ? Digital X-ray radiogrammetry (DXR) predicts hip fracture risk in both women and men. ? Osteoporosis can potentially be identified in patients with suspected wrist fractures. ? DXR can potentially be used for selective osteoporosis screening.     

Morphologic characterization of meniscal root ligaments in the human knee with magnetic resonance microscopy at 11.7 and 3 T

Objective

To determine the feasibility of using MR microscopy to characterize the root ligaments of the human knee at both ultra-high-field (11.7 T) and high-field (3 T) strengths.

Materials and methods

Seven fresh cadaveric knees were used for this study. Six specimens were imaged at 11.7 T and one specimen at 3 T using isotropic or near-isotropic voxels. Histologic correlation was performed on the posteromedial root ligament of one specimen. Meniscal root ligament shape, signal intensity, and ultrastructure were characterized.

Results

High-resolution, high-contrast volumetric images were generated from both MR systems. Meniscal root ligaments were predominantly oval in shape. Increased signal intensity was most evident at the posteromedial and posterolateral root ligaments. On the specimen that underwent histologic preparation, increased signal intensity corresponded to regions of enthesis fibrocartilage. Collagen fascicles were continuous between the menisci and root ligaments. Predominantly horizontal meniscal radial tie fibers continued into the root ligaments as vertical endoligaments.

Conclusion

MR microscopy can be used to characterize and delineate the distinct ultrastructure of the root ligaments on both ultra-high-field- and high-field-strength MR systems.     

Chemoembolization for Hepatocellular Carcinoma Supplied Exclusively by the Hepatic Falciform Artery

Purpose

The purpose of this study was to describe imaging appearances of hepatocellular carcinoma (HCC) supplied exclusively by the hepatic falciform artery (HFA) and safety of chemoembolization via the HFA.

Methods

During the past 6?years, we have performed chemoembolization for the treatment of 12 patients with HCCs supplied exclusively by the HFA. Computed tomography (CT) scans, digital subtraction angiograms, and medical records were retrospectively reviewed by consensus.

Results

Tumors were located in Couinaud segments IV (n?=?7) and III (n?=?5) and in subcapsular areas around the falciform ligaments. Tumor size ranged from 1.0 to 1.8?cm (mean, 1.3?cm; median, 1.3?cm). HFAs originated from A4 (n?=?7), A3 (n?=?4), and the left hepatic artery near the umbilical point (n?=?1). All tumors were supplied exclusively by the HFA. Prophylactic embolization of the distal HFA before chemoembolization was performed using gelatin sponge particles in only one patient, and selective chemoembolization via the HFA was achieved in all patients. One patient suffered from a skin rash after chemoembolization and recovered after conservative management. Individual responses of tumors supplied exclusively by the HFA were complete response (n?=?8), partial response (n?=?1), and stable disease (n?=?2) at the first follow-up enhanced CT scan.

Conclusions

The HFA can supply HCC located in subcapsular areas around the falciform ligament, and the tumors can be safely chemoembolized without significant complications.     

Forces acting on the anterior meniscotibial ligaments

Purpose

The purpose of this study was to investigate the forces occurring in human anterior meniscotibial attachment structures under various loading conditions.

Methods

Twelve human knee joints were exposed to eight loading conditions (tibial rotations and varus/valgus stress) using a previously described knee joint simulator. Subsequently, the joints were axially compressed (1,000?N at 0° 30° and 60° knee flexion) using a materials testing machine. Then, we performed a tensile test to failure of the ligaments. Finally, we used the strains that occurred during the loading tests and the force–elongation diagrams obtained from the tensile test to recursively assess the resulting forces.

Results

In the anterior meniscotibial ligaments, we found maximum mean strains of 3.8?±?2.3% under external moments and 1.5?±?0.9% for axial compression. With an ultimate load of 454?±?220?N for the anterolateral meniscotibial ligament and 397?±?275?N for the anteromedial meniscotibial ligament, we estimated maximum forces of up to 50.2?N for the knee simulator tests and 22.6?N for the axial compression tests.

Conclusions

The low forces found in the meniscal ligaments suggest that for normal daily activities, meniscal replacement implants and allografts do not require a very rigid fixation at their bony insertions. However, it remains unknown, what level of force occurs in the meniscotibial ligaments under traumatic situations or impact knee loads. Furthermore, the results of the present study could help to optimize meniscal re-fixation and to improve the properties of meniscal replacement materials, such as tissue-engineered artificial menisci. Moreover, the results could be used for the validation of finite element models of the knee joint with the main focus on the meniscus and its biomechanical relevance for tibiofemoral contact pressure.     

Thickening of the inferior glenohumeral capsule: an ultrasound sign for shoulder capsular contracture

Objectives

The aim of this retrospective study was to measure the inferior glenohumeral capsule thickness of shoulders clinically affected by capsular contracture by comparison to the contralateral asymptomatic side.

Methods

Bilateral shoulder ultrasound (US) examinations of 20 patients with clinically or MRI proven unilateral capsular contracture were retrospectively assessed. Inferior capsule evaluation was performed with a transducer placed within the axilla in maximally abducted shoulders. Measurements were symmetrically performed orthogonally to the inferior glenohumeral ligament (IGHL) in the axial plane; the coronal plane was used to ensure the tension of the IGHL. The significance of any difference in thickening was assessed with the Mann–Whitney test.

Results

The average thickness was 4.0 mm in shoulders with capsular contracture vs. 1.3 mm in asymptomatic contralateral shoulders (P?<?0.0001). Twenty per cent of patients with capsular contracture and inferior capsule thickness increase showed US features of other painful diseases of the rotator cuff.

Conclusion

The thickness of the inferior capsule is measurable through ultrasound examination and appears to be increased in shoulders with capsular contracture. Exploration of the inferior aspect of the shoulder joint could be added to shoulder US examination protocols for capsular contracture assessment even if other rotator cuff abnormalities are diagnosed by US.

Key Points

? Ultrasound is increasingly used to diagnose shoulder problems. ? The thickness of the inferior glenohumeral ligament is measurable in the axilla. ? The inferior glenohumeral ligament appears thickened in shoulders with capsular contracture. ? Capsular contracture ultrasound features can be associated with other rotator cuff problems.     

The carpometacarpal joint of the thumb: MR appearance in asymptomatic volunteers

Purpose

To prospectively characterize the MR appearance of the carpometacarpal (CMC) joint of the thumb in asymptomatic volunteers.

Materials and methods

Thirty-four asymptomatic volunteers (17 women, 17 men, mean age, 33.9?±?9.2 years) underwent MR imaging of the thumb after approval by the local ethical committee. Two musculoskeletal radiologists independently classified visibility and signal intensity (SI) characteristics of the anterior oblique (AOL/beak ligament), the posterior oblique (POL), the intermetacarpal (IML), and the dorsoradial ligaments (DRL) on a three-point Likert scale. The thickness of all ligaments, cartilage integrity, and presence of joint fluid were assessed. The alignment of the first metacarpal base with the trapezium was quantified on sagittal and coronal planes.

Results

The ligaments of the CMC joint were constantly visible in all volunteers for the POL and IML, and in all but one for the AOL and DRL. On intermediate-weighted fat-saturated images the POL (65 %/74 % reader 1/reader 2) and DRL (58 %/64 %) were commonly of increased SI, while the IML had a striated appearance in 91 %/76 % of subjects. The AOL showed a variable SI (36 %/42 % low, 27 %/27 % increased, 36 %/30 % striated). The IML was the thickest ligament with a mean of 2.9 mm/3.1 mm and the DRL the thinnest (1.2 mm/1.4 mm). There was a mean dorsal subluxation of 1.8 mm/2.0 mm and radial subluxation of 2.8 mm/3.4 mm of the metacarpal base. The AOL was significantly thicker in men (1.7 mm) than in women (1.2 mm; p?=?0.02). Radial subluxation was significantly larger in men (3.4 mm) than in women (2.2 mm; p?=?0.02). No subluxation in palmar or ulnar direction was seen.

Conclusions

Radial and dorsal subluxation of the CMC joint can be a normal finding in a resting position at MR imaging. The CMC ligaments showed a considerable variability of signal intensity with a typically striated IML; thickness of the AOL is typically less than 2.2 mm, of the POL typically less than 2.9 mm.     

Primary ligament sutures as a treatment option of knee dislocations: a meta-analysis

Purpose

Treatment of knee dislocation is still controversial. There is no evidence to favour ligament suture or reconstruction. Until now, no meta-analyses have examined suture versus reconstruction of cruciate ligaments in knee dislocations with respect to injury pattern and rupture classification.

Methods

We searched Medline, the Cochrane Controlled Trial Database, and EMBASE for studies on surgical treatment for ‘knee dislocation’ and ‘multiple ligament injured knee’. A meta-analysis was performed using individual patient data.

Results

Nine studies including 195 patients (200 knees) with a mean age of 31.4 (±13) years fulfilled the study requirements. Thirteen cases of type II dislocations, 63 cases of type III medial, 84 cases of type III lateral, and 40 cases of type IV dislocations, according to Schenck’s classification, were found. Poor or moderate results were found in 70 % of patients without surgical treatment of ACL or PCL (n = 27). Patients (n = 40) treated by sutures of the ACL and PCL demonstrated a significantly greater proportion of excellent or good results (40 and 37.5 %, respectively) (p < 0.001). Patients who underwent reconstruction of the ACL and PCL (n = 75) showed excellent or good results (28 and 45 %, respectively). No significant difference was found when comparing suture versus reconstruction of the ACL and PCL (n.s.). The outcome depends considerably on Schenck’s injury pattern classification.

Conclusion

Conservative treatment after knee dislocation yields poor clinical results. Suture repair of cruciate ligaments can still serve as an alternative option for multiligament injuries of the knee and achieve good clinical results, which are comparable to those of ligament reconstruction. The data provided by this meta-analysis should be reinforced by a prospective study, in which suture repair and ligament reconstruction are compared.

Level of evidence

IV.     

Injuries of the scapholunate and lunotriquetral ligaments as well as the TFCC in intra-articular distal radius fractures. Prevalence assessed with MDCT arthrography

Objectives

To evaluate the prevalence of injuries of the scapholunate and lunotriquetral interosseous ligaments (SLIL, LTIL) as well as the triangular fibrocartilage complex (TFCC) in intra-articular distal radius fractures (iaDRF).

Methods

Two hundred and thirty-three patients with acute iaDRF underwent MDCT arthrography. The SLIL and LTIL were described as normal, partially or completely ruptured. Major injuries of the SLIL were defined as completely ruptured dorsal segments, those of the LTIL as completely ruptured palmar segments. The TFCC was judged as normal or injured. Interobserver variability was calculated. Injury findings were correlated with the types of iaDRF (AO classification).

Results

In 159 patients (68.2 %), no SLIL injuries were seen. Minor SLIL injuries were detected in 54 patients (23.2 %), major injuries in 20 patients (8.6 %). No correlation was found between the presence of SLIL lesions and the types of iaDRF. Minor LTIL injuries were seen in 23 patients (9.9 %), major injuries in only 5 patients (2.2 %). The TFCC was altered in 141 patients (60.5 %). Interobserver variability was high for MDCT arthrography in assessing SLIL and TFC lesions, and fair for LTIL lesions.

Conclusion

In iaDRF, prevalence of major injuries of the most relevant SLIL is about 9 % as evaluated with CT arthrography.

Key Points

? The C-shaped SLIL is built of dorsal, middle and palmar segments. ? In iaDRF, major SLIL injuries are associated in 8.6 % of the cases. ? In iaDRF, the SLIL remains intact in 68.3 % of the cases. ? IaDRF and SLIL ruptures can comprehensively be depicted with MDCT arthrography. ? A three-compartment approach is recommended to assess intrinsic ligaments and the TFCC.

     

Cartilage quality in rheumatoid arthritis: comparison of T2* mapping, native T1 mapping, dGEMRIC, ΔR1 and value of pre-contrast imaging

Purpose

To prospectively evaluate four non-invasive markers of cartilage quality—T2* mapping, native T1 mapping, dGEMRIC and ΔR1—in healthy volunteers and rheumatoid arthritis (RA) patients.

Materials and methods

Cartilage of metacarpophalangeal (MCP) joints II were imaged in 28 consecutive subjects: 12 healthy volunteers [9 women, mean (SD) age 52.67 (9.75) years, range 30–66] and 16 RA patients with MCP II involvement [12 women, mean (SD) age 58.06 (12.88) years, range 35–76]. Sagittal T2* mapping was performed with a multi-echo gradient-echo on a 3?T MRI scanner. For T1 mapping the dual flip angle method was applied prior to native T1 mapping and 40?min after gadolinium application (delayed gadolinium-enhanced MRI of cartilage, dGEMRIC, T1_Gd). The difference in the longitudinal relaxation rate induced by gadolinium (ΔR1) was calculated. The area under the receiver operating characteristic curve (AROC) was used to test for differentiation of RA patients from healthy volunteers.

Results

dGEMRIC (AUC 0.81) and ΔR1 (AUC 0.75) significantly differentiated RA patients from controls. T2* mapping (AUC 0.66) and native T1 mapping (AUC 0.66) were not significantly different in RA patients compared to controls.

Conclusions

The data support the use of dGEMRIC for the assessment of MCP joint cartilage quality in RA. T2* and native T1 mapping are of low diagnostic value. Pre-contrast T1 mapping for the calculation of ΔR1 does not increase the diagnostic value of dGEMRIC.     

Diffusion-weighted MR neurography of median and ulnar nerves in the wrist and palm

Objectives

To investigate the feasibility of diffusion-weighted magnetic resonance neurography (DW-MRN) in the visualisation of extremity nerves in the wrist and palm.

Methods

Thirty-two volunteers and 21 patients underwent imaging of the wrist and palm on a 3-T MR scanner. In all subjects, two radiologists evaluated the image quality on DW-MRN using a four-point grading scale. Kappa statistics were obtained for inter-observer performance. In volunteers, the chi-squared test was used to assess the differences in nerve visualisation on DW-MRN and axial fat-suppressed proton density weighted imaging (FS-PDWI).

Results

In volunteers, the mean image quality scores for the median nerve (MN) and ulnar nerve (UN) were 3.71?±?0.46 and 3.23?±?0.67 for observer 1, and 3.70?±?0.46 and 3.22?±?0.71 for observer 2, respectively. The inter-observer agreement was excellent (k?=?0.843) and good (k?=?0.788), respectively. DW-MRN provided significantly improved visualisations of the second and the third common palmar digital nerves and three branches of UN compared with FS-PDWI (P?<?0.05). In patients, the mean image quality scores for the two observers were 3.24?±?0.62 and 3.10?±?0.83, inter-observer performance was excellent (k?=?0.842).

Conclusions

DW-MRN is feasible for improved visualisation of extremity nerves and their lesions in the wrist and palm with adequate image quality, thereby providing a supplementary method to conventional MR imaging.

Key points

? DW-MRN provides adequate image quality for wrist and palm neurography ? DW-MRN performs similarly to FS-PDWI in nerve visualisation at the wrist ? DW-MRN provides improved visualisation of small nerves in the palm ? DW-MRN serves as a supplementary method to evaluate peripheral neuropathies