Use and abuse of magnetic resonanceimaging in sports medicine

MRI (magnetic resonance imaging) is a non-invasive imaging modality used in the evaluation of musculoskeletal injury. It has provided a specific advantage in the athletic population given the numerous soft-tissue injuries which are encountered. The work-up of the injured athlete, however, must include a careful history, complete physical examination and appropriate use of plain radiographs. The MRI should be used as an adjunct and not as a substitute for thorough clinical evaluation. The future management of sport-related musculoskeletal injury will undoubtedly be shaped by MRI and its related technologies.     

Magnetic resonance imaging of musculoskeletal neoplasms

Magnetic resonance imaging (MRI) has become a valuable technique in the evaluation of the musculoskeletal system. Its superior soft-tissue contrast and its ability to image in multiple planes provide significant advantages over other imaging techniques, including computed tomography. MRI has been particularly useful in the detection and staging of musculoskeletal neoplasms. Currently, it is the technique of choice for the evaluation of soft-tissue masses and many skeletal neoplasms. MRI is also useful in the evaluation of metastasis. The role of MRI in differentiating recurrent neoplasms from postoperative and radiation changes continues to evolve; spectroscopy may add considerable specificity in this setting.     

Trigger digits: diagnosis and treatment

Stenosing tenosynovitis of the thumb and fingers is a very common problem seen by the primary-care physician, the orthopaedic surgeon, and the hand surgeon. Primary stenosing tenosynovitis is usually idiopathic and occurs more frequently in middle-aged women than in men, but can be seen even in infancy. Secondary stenosing tenosynovitis of the digits can occur in patients with rheumatoid arthritis, diabetes mellitus, gout, and other disease entities that cause connective tissue disorders. The diagnosis of triggering digits is generally not subtle and can be made on the basis of an adequate clinical examination. Classification according to the type of tenosynovitis and the time from onset of symptoms may be prognostically significant and may also affect the treatment outcome. As many as 85% of triggering fingers and thumbs can be treated successfully with corticosteroid injections and nonsteroidal anti-inflammatory drugs. Surgical release is generally indicated when nonoperative treatment fails. Percutaneous A1 pulley release can now be performed safely as an office procedure.     

Magnetic resonance imaging of the spine

The role of magnetic resonance imaging (MRI) for the evaluation of the spine is expanding rapidly. In addition to being noninvasive, MRI offers high soft-tissue contrast and multiplanar imaging capability. MRI examinations of the spine usually include a T1-weighted spin-echo and a T2-weighted spin-echo and/or a gradient-echo sequence. As in other parts of the body, the use of surface coils results in higher-quality examinations. Various methods are employed to reduce the motion artifacts that are particularly troublesome in spine imaging. Paramagnetic contrast agents are used to enhance soft-tissue lesions. The contrast sensitivity of MRI provides a unique means to assess the intervertebral disc, and MRI is rapidly becoming the method of choice for evaluation of disc disease. It is also very sensitive and accurate in the detection of osteomyelitis of the spine. MRI has improved the evaluation of failed back surgery syndrome, and the administration of gadolinium-diethylene trimene pentacidic acid helps to differentiate postsurgical scar from recurrent disc herniation. MRI is an unparalleled tool for the detection and evaluation of intramedullary lesions including syringomyelia, gliomas, hematomas, and lesions associated with dysraphism. It is also useful in many extramedullary intradural processes. In summary, MRI is the best first examination for spinal disease.     

Diagnosis of acute rupture of the quadriceps tendon by magnetic resonance imaging. A case report

Quadriceps tendon rupture occurred in a 56-year-old man receiving anticoagulant therapy. The diagnosis was inconclusive until magnetic resonance imaging (MRI) was used to delineate the rupture site clearly. MRI is a useful adjunct to diagnosis of soft-tissue injuries in cases in which swelling or other soft-tissue abnormalities obscure examination or preclude the use of more routine diagnostic modalities.     

Diagnosing,planning and evaluating osteochondral ankle defects with imaging modalities

This current concepts review outlines the role of different imaging modalities in the diagnosis, preoperative planning, and follow-up of osteochondral ankle defects. An osteochondral ankle defect involves the articular cartilage and subchondral bone (usually of the talus) and is mostly caused by an ankle supination trauma. Conventional radiographs are useful as an initial imaging tool in the diagnostic process, but have only moderate sensitivity for the detection of osteochondral defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are more accurate imaging modalities. Recently, ultrasonography and single photon emission CT have been described for the evaluation of osteochondral talar defects. CT is the most valuable modality for assessing the exact location and size of bony lesions. Cartilage and subchondral bone damage can be visualized using MRI, but the defect size tends to be overestimated due to bone edema. CT with the ankle in full plantar flexion has been shown a reliable tool for preoperative planning of the surgical approach. Postoperative imaging is useful for objective assessment of repair tissue or degenerative changes of the ankle joint. Plain radiography, CT and MRI have been used in outcome studies, and different scoring systems are available.     

Cross-Sectional Imaging in Evaluation of Soft Tissue Reactions Secondary to Metal Debris

An integral component of systematic treatment algorithms to optimize evaluation and management of patients with MoM hip arthroplasty recommend the use of cross-sectional imaging to diagnose the presence of adverse local tissue reactions. Cross-sectional imaging studies such as ultrasound is a useful screening tool to detect the presence of a soft-tissue mass adjacent to a MoM implant. MARS MRI is a useful diagnostic test for assessing MoM hip arthroplasty and modular taper corrosion for adverse tissue reactions. Each cross-sectional imaging modality has unique utility and limitations. As metal artifact reduction technique continues to be refined, the utility of MARS MRI in evaluating patients with MoM hip arthroplasty and modular taper corrosion is likely to have an increased role in the clinical decision making process. However, over-reliance on any single investigative tool in the clinical decision-making process should be avoided.     

克罗恩病肛瘘的影像学诊断

舡瘘是克罗恩病最常见的肛周病变．且多为复杂性肛瘘,治疗困难．复发率高．严重影响患者的生活质量。为了获得最佳的临床疗效．治疗前及治疗过程中精确地进行疾病评估十分重要。影像学检查是评估克罗恩病肛瘘的重要手段,可以明确诊断、准确分型、辅助制定最合适的治疗方案和进行疗效监测。磁共振成像（MRI）和直肠超声内镜（EUS）[或直肠腔内超声（AES）]被认为是评估原发克罗恩病肛瘘的最佳选择,具有较高的特异性和敏感性,而MRI对于监测克罗恩病肛瘘的治疗效果更有优势。瘘管造影由于软组织分辨力较差和有辐射损伤等原因,临床上已经较少应用。本文通过分析各种影像学检查方法及其各自的优势与不足．旨在帮助临床医生为患者选择个体化的最优检查手段。     

Hip arthroscopy in staging avascular necrosis of the femoral head

The purposes of this study were to evaluate how accurately current imaging modalities predict the quality of the articular surface in avascular necrosis (AVN) of the femoral head and to provide arthroscopic correlation to current staging modalities. An arthroscopic classification system, derived from the work of Marcus et al, was used to prospectively stage the articular surface in 23 hips with AVN using plain radiographs, magnetic resonance imaging (MRI), and arthroscopy. There was little correlation between all three diagnostic modalities. These findings were not statistically significant. Patients with stage IV disease had the widest variation in the appearance of the articular surface. This study shows poor correlation in the staging of AVN using current imaging techniques. Magnetic resonance imaging has been shown to be inadequate at assessing the articular cartilage. Therefore, either arthroscopy or direct visualization is required for accurate evaluation and staging, especially in stage IV disease.     

De quervain tenosynovitis of the wrist

De quervain disease, or stenosing tenosynovitis of the first dorsal compartment of the wrist, is a common wrist pathology. Pain results from resisted gliding of the abductor pollicis longus and the extensor pollicis brevis tendons in the fibro-osseus canal. de Quervain tenosynovitis of the wrist is more common in women than men. Diagnosis may be made on physical examination. Radiographs are helpful in ruling out offending bony pathology. Nonsurgical management, consisting of corticosteroid injections and supportive thumb spica splinting, is usually successful. In resistant cases, surgical release of the first dorsal compartment is done, taking care to protect the radial sensory nerve and identify all accessory compartments. Repair of the extensor retinaculum by step-cut lengthening or other techniques is rarely required.     

Stenosing synovitis of the extensor pollicis longus tendon

There are only a few published cases of extensor pollicis longus (EPL) tenosynovitis in patients without rheumatoid arthritis. Even less common are cases of stenosing tenosynovitis of the EPL associated with triggering. This article presents 2 cases of EPL stenosing tenosynovitis with triggering of the thumb in the area of Lister's tubercle and addresses how to treat them.     

Imaging of degenerative disease of the cervical spine

The introduction of new techniques to the magnetic resonance imaging (MRI) armamentarium is beginning to provide an MRI examination that overcomes many of the disadvantages noted in earlier reports. An analysis of the various advantages and disadvantages of MRI, plain film myelography, and computed tomographic myelography points to a potential revision of the sequence of diagnostic studies and the workup of cervical degenerative disease. MRI might now be the appropriate first test for the evaluation of the cervical spine in a patient with symptoms referable to degenerative disease when therapeutic intervention is considered. An initial T1-weighted sagittal image with a 3-mm slice thickness will provide excellent contrast evaluation of the vertebral body marrow, disc space height, neural canal, and spinal cord. Disc herniation, canal stenosis, subluxation, and malalignment can be appreciated. Next, a fast, variable flip angle, gradient-echo sequence can be performed to increase the signal density of the cerebrospinal fluid relative to the extradural elements and cord. This provides an increased conspicuousness of extradural disease. Axial gradient-echo fast sequences, with low flip angles, will provide a second orthogonal plane with increased conspicuousness of extradural changes relative to the neural foramen and thecal sac. If necessary, additional oblique views through the neural foramen can be obtained. Finally, if intramedullary disease is considered in the differential, a gated, refocused, T2-weighted examination in the sagittal plane will provide the necessary soft-tissue contrast to detect pathology without unwanted artifact. Thus, unlike plain film or computed tomographic myelography, an examination of the entire cervical region including the osseous structures, extradural cerebrospinal fluid interface, and the spinal cord can be obtained with a single modality in an outpatient setting and in a noninvasive fashion. MRI can certainly replace plain film myelography for the overwhelming majority of situations. If surface-coil MRI fails to demonstrate an abnormality responsible for the patient's clinical symptoms, then a high-resolution computed tomographic scan with or without intrathecal contrast can be obtained. While the cost at first may seem prohibitive, the additional information that MRI is capable of providing in a noninvasive outpatient setting more than compensates for the expense.     

Extensor triggering in de Quervain's stenosing tenosynovitis

Extensor triggering is an uncommon but recognized component of de Quervain's stenosing tenosynovitis. In a retrospective review of 827 patients with the diagnosis of de Quervain's disease over a 5-year period, 11 patients with 13 affected wrists were identified who had demonstrable triggering by both history and physical examination (prevalence of 1.3%). One wrist underwent surgical release without conservative treatment. The remaining 12 wrists were initially treated with nonoperative modalities. Failure of conservative treatment as defined by recurrent triggering and pain occurred in 7 wrists, of which 5 underwent surgical release. At the time of surgery, all wrists were noted to have synovitis, separate compartments for the extensor pollicis brevis and abductor pollicis longus tendons, and no intratendinous nodules. After an average follow-up period of 42 months (range, 5.7-94.5 months) there were no recurrences of triggering after surgical treatment. Seven of 12 wrists with triggering de Quervain's stenosing tenosynovitis failed nonoperative treatment. Triggering or locking in extension is an uncommon symptom in de Quervain's stenosing tenosynovitis and demonstrates a more recalcitrant course when treated nonoperatively.     

Power Doppler ultrasonographic assessment of the ankle in patients with inflammatory rheumatic diseases

Ankle involvement is frequent in patients with inflammatory rheumatic diseases, but accurate evaluation by physical examination is often difficult because of the complex anatomical structures of the ankle. Over the last decade, ultrasound (US) has become a practical imaging tool for the assessment of articular and periarticular pathologies, including joint synovitis, tenosynovitis, and enthesitis in rheumatic diseases. Progress in power Doppler (PD) technology has enabled evaluation of the strength of ongoing inflammation. PDUS is very useful for identifying the location and kind of pathologies in rheumatic ankles as well as for distinguishing between inflammatory processes and degenerative changes or between active inflammation and residual damage. The aim of this paper is to illustrate the US assessment of ankle lesions in patients with inflammatory rheumatic diseases, including rheumatoid arthritis, spondyloarthritis, and systemic lupus erythematosus, focusing on the utility of PDUS.     

桡骨茎突狭窄性腱鞘炎的治疗进展

桡骨茎突狭窄性腱鞘炎,是一种常见的慢性运动系统损伤疾病,多引起关节处疼痛并伴活动时加重,对人们的日常生活造成影响。目前针对此病的治疗方法较多且各有疗效,可以分为保守治疗和手术治疗两种。本病的治疗难点在于根治,保守治疗常常能在急性期缓解疼痛,改善腕部功能,但其远期作用甚微,容易复发。手术治疗能够提高本病的治愈率,但作为有创治疗,存在一系列风险,当遇到顽固性桡骨茎突狭窄性腱鞘炎时才建议选用。笔者认为,患者教育为治疗中重要一环,并且对本病进行分级,根据疾病发展的不同情况合理选用多种手法综合治疗本病,能够有效治愈本病。     

Imaging the spine

The spine can be assessed using different imaging modalities, each offering their own advantages and limitations. The decision to use a certain type of imaging should be based on a number of factors which include the clinical question to be answered, the speed that answer is needed, the availability of an imaging modality and patient compatibility. We aim to discuss how to best use imaging when investigating spinal pathologies, consider the advantages and limitations of each imaging modality and demonstrate annotated examples of pathology on imaging.     

Diagnosis of osteoarthritis: imaging

Osteoarthritis (OA) is a chronic, debilitating joint disease characterized by degenerative changes to the bones, cartilage, menisci, ligaments, and synovial tissue. Imaging modalities such as radiography, magnetic resonance imaging (MRI), optical coherence tomography (OCT), and ultrasound (US) permit visualization of these structures and can evaluate disease onset and progression. Radiography is primarily useful for the assessment of bony structures, while OCT is used for evaluation of articular cartilage and US for ligaments and the synovium. MRI permits visualization of all intraarticular structures and pathologies, though US or OCT may be preferential in some circumstances. As OA is a disease of the whole joint, a combination of imaging techniques may be necessary in order to gain the most comprehensive picture of the disease state. This article is part of a Special Issue entitled "Osteoarthritis".     

Imaging in rheumatoid arthritis of the elbow

Early specific radiologic changes of rheumatoid arthritis can usually be detected in the hands and feet. Later stages of the disease process show a typical centripetal spread of the affected joints, i.e., shoulder, elbow, and knee. For prognostic assessment of cubital rheumatoid arthritis, conventional radiography still remains the gold standard. X-rays allow objective scoring and thus classification into standardized stages. A concentric destruction of the rheumatic joint as compared to deformity in the degenerative joint is the typical radiologic symptom to look for. For soft tissue assessment, ultrasound (US) should be the diagnostic tool of choice. Due to the thin surrounding soft tissue layer, as well as the advanced high-resolution technology, bony structures can also be well demonstrated in any plane. In the early arthritic stages, particularly the small changes, e.g., minimal erosions of the cortical area, are very well detectable by US. The use of "color" allows good evaluation of the synovial inflammatory status. Modern imaging methods such as computer- assisted tomography (CAT) scan and magnetic resonance imaging (MRI) are restricted to a few set indications and should not be chosen for routine examination. More invasive methods such as arthrography are no longer indicated for assessment of cubital rheumatoid arthritis.     

MRI of the musculoskeletal system.

MRI is rapidly altering the presurgical evaluation for many forms of musculoskeletal pathology, and the indications for MRI will undoubtedly continue to grow. Because of the complexity of this modality and the ability to totally "miss" pathology by the inappropriate choice of imaging plane or pulse sequence, cooperation between the orthopedic surgeon and the radiologist is essential. A close working relationship is required for maximum diagnostic information to be obtained with each examination and for optimal patient care.     

Wertigkeit der Magnetresonanztomographie in der Diagnostik von TFCC-Läsionen

When a clinical examination gives rise to the suspicion of a lesion of the triangular fibrocartilage complex (TFCC), diagnostic imaging is performed to limit the differential diagnoses and to avoid unneccessary invasive procedures. MRI has lately come to be regarded as an alternative to arthrography in such cases. The diagnostic accuracy of MRI in the evaluation of TFCC lesions depends, among other things, on the imaging technique used, the experience of the practitioner conducting the examination and the localisation of the lesion. Lesions on the ulnar side are more difficult to diagnose than central or radial lesions. The specificity of MRI for TFCC lesions is lower than its sensitivity, false-positive results seem to be more of a problem than undetected lesions in day-to-day clinical practice. Despite these limitations, MRI is still the best imaging modality for assessment of a suspected TFCC pathology. Optimal results can only be achieved by an experienced practitioner using a focused imaging technique in a cooperative patient, and then only if sufficient clinical information is available. The intraarticular administration of contrast medium clearly improves the prognostic value but is confined to specific indications owing to the added cost and the invasiveness (although this is limited).