Gray-scale and color Doppler ultrasonographic evaluation of reactivated post-traumatic/postoperative chronic osteomyelitis

Objective  We aimed to carry out a systematic assessment of gray-scale and color Doppler ultrasonography (CDUS) findings of reactivated post-traumatic/postoperative chronic osteomyelitis (COM) in adults. Materials and methods  Gray-scale and color Doppler ultrasonography were performed on 40 consecutive patients with a history of long-standing post-traumatic/post-operative chronic osteomyelitis and clinical suggestion of reactivation, in a 32-month-period. All patients had metallic implants: 16 internal fixations, nine external fixations, 11 hip arthroplasties and four knee arthroplasties. The final diagnosis of reactivated COM was based upon biopsy findings, with microbiological and histological examination (n = 27), or a combination of laboratory, clinical and magnetic resonance (MR) findings (n = 13). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of sonographic signs, including fistulous tracts, periosteal thickening, cortical discontinuity, soft tissue abscess and cellulitis, juxtacortical fluid, distension of the pseudocapsule in arthroplasties, and periosteal vascularity, were estimated. Results  Statistically significant differences between patients with and without reactivated COM were found for fistulous tracts (P < 0.0001), juxtacortical fluid collections (P < 0.001) periosteal thickening (P < 0.01), distension of pseudocapsule (P < 0.05), and periosteal vascularity (P < 0.0001). Low-resistance arterial flow of periosteal vessels presented the highest sensitivity (92%), specificity, and PPV (100%), yielding only two false negative results in two obese patients. Among gray-scale findings, the presence of a fistulous tract yielded the highest specificity and PPV (100%), whereas periosteal thickening was the most sensitive (92%), though not specific, finding (specificity 50%). Conclusion  A constellation of gray-scale and CDUS findings can be highly indicative of reactivated bone infection in patients with long-standing chronic post-traumatic/post-operative osteomyelitis.     

Magnetic resonance findings in chronic osteomyelitis fistula

INTRODUCTION: Osteomyelitis is a common inflammatory process caused by an infection which is usually from gram-positive germs. Acute, subacute and chronic forms can be distinguished both clinically and radiographically, each of them presenting different patterns but which are not always easy to recognize. Besides clinical-laboratory data, imaging methods are also useful to make the diagnosis; in chronic forms, MRI has higher sensitivity in recognizing the active foci and the presence of sinus tracts than the other techniques. MATERIAL AND METHODS: We examined nine patients with suspected chronic osteomyelitis with a sinus tract, all of them submitted to radiographic and MR examinations. MRI was performed with a .5 T magnet using a surface coil for joint studies; T1-weighted SE (TR 300-500, TE 20), T2-weighted GE (TR 500-700, TE 20, FA 35 degrees) and FIR sequences with fat suppression (TR 3000, TE 20, TI 100) were performed on the axial, sagittal and coronal planes. Three patients underwent CT too. RESULTS: Radiography showed the osteostructural changes as osteolytic and osteosclerotic areas. CT depicted not only the changes seen radiographically, but also increased bone marrow density. MRI demonstrated active foci of bone marrow appearing as low-intensity areas in T1, with increased intensity in T2 GE and fat-suppressed FIR images; it also depicted the sinus tracts as areas of decreased signal on T1 and of increased signal on FIR images. CONCLUSIONS: Based on our experience and in agreement with the literature data, we believe that MRI is more useful to diagnose the active foci of bone marrow and the sinus tracts in chronic osteomyelitis, especially with T1-weighted SE and fat-suppressed FIR sequences.     

Computed tomography findings of chronic osteomyelitis involving the mandible: correlation to histopathological findings

OBJECTIVES: The aim of this study is to discuss the pathological course of chronic osteomyelitis of the mandible by investigating a correlation between CT and histopathological findings and to argue the usefulness of CT examination in the evaluation of mandibular chronic osteomyelitis. METHODS: CT images obtained between 1997 and 2004 of 62 lesions in 60 patients with chronic osteomyelitis involving the mandible were reviewed retrospectively. CT images obtained at initial examination or pre-operative evaluation were reviewed and CT findings of affected bone were classified into three patterns: bone-defect pattern, frosted-glass pattern and compact-bone pattern. In 7 of 62 lesions, CT images and histopathological specimens were selected to obtain a side-by-side comparison in order to clarify what histopathological features reflect those three patterns of CT findings. Additionally, the correlations among the three patterns in the course of mandibular chronic osteomyelitis were also assessed. RESULTS: The areas of bone-defect pattern, frosted-glass pattern and compact-bone pattern observed on CT images were revealed to indicate fibre-rich granulation tissue, new formation of bony trabeculae and thickening of bony trabeculae on histopathological findings, respectively. CONCLUSIONS: It was considered that these three patterns are significant in the evaluation of the process of the course of chronic osteomyelitis. We advocate that CT is useful to grasp the complex pathological conditions of chronic mandibular osteomyelitis.     

Unusual bone-scan findings in acute osteomyelitis: case report.

In osteomyelitis, bone-scan findings precede the appearance of bone changes on radiographs. In cases where focal ischemia occurs, the earliest scan finding may be a "cold" area that later becomes "hot" as active periostitis develops.     

Scintigraphic findings in chronic actinomycosis osteomyelitis and associated soft tissue infection

Scintigraphic findings are reported in a patient with actinomycosis osteomyelitis and soft tissue infection to illustrate the need to understand the mechanism of localization of the radiopharmaceutical to accurately assess the clinical pathology.     

Cold osteomyelitis. Radionuclide bone scan findings

Absence of Tc-99m MDP accumulation in bone may be due to various causes, including infection, infarction, neoplasm, foreign bodies, or artefacts (1,2). In our patient, absence of radionuclide was noted in the proximal metaphyseal region of his left tibia, along with increased activity distally. These findings were attributed to a "cold" osteomyelitis caused by pus beneath the periosteum. Initial x-rays were interpreted as normal, while subsequent films demonstrated gross abnormalities. Few cases of cold osteomyelitis have been reported.     

Slipped capital femoral epiphysis: ultrasonographic findings

Slipped capital femoral epiphysis (SCFE) is an uncommon skeletal disorder of adolescence often overlooked because of its nonspecific clinical presentation. Anteroposterior radiography may fail to demonstrate a minimal slip even when clinical examination raises suspicion of the disease. On the other hand, prompt diagnosis is essential to obtain better therapeutic results. In our patient population joint effusion, which often accompanies SCFE, was readily recognized and quantified by ultrasonography (US). US also permitted recognition of the initial SCFE and assessment of the degree of slip by measuring the height of the physeal step. As to metaphyseal remodeling, plain radiography seems to be more informative than US; however, US has a role in the follow-up of SCFE because of the risk of slippage in the contralateral hip. This work suggests that US is useful as a primary imaging tool in the evaluation of subjects with limp or hip or knee pain to rule out SCFE.     

Budd-Chiari syndrome: computed tomographic and ultrasonographic findings

A case of Budd-Chiari syndrome is presented in which computed tomography (CT) and ultrasonography suggested the correct diagnosis and excluded adjacent tumor as the cause of hepatic vein occlusion. The CT appearance in this case (homogeneously increased attenuation of an enlarged caudate lobe) differed from the appearance previously reported (patchy liver enhancement) in Budd-Chiari syndrome. Underlying mechanisms responsible for the different CT appearance are discussed.     

Blunt trauma to the spleen: ultrasonographic findings

The spleen is the most frequently injured organ in adults who sustain blunt abdominal trauma. Splenic trauma accounts for approximately 25% to 30% of all intra-abdominal injuries. The management of splenic injury has undergone rapid change over the last decade, with increasing emphasis on splenic salvage and non-operative management. Identifying the presence and degree of splenic injury is critical in triaging the management of patients. Imaging is integral in the identification of splenic injuries, both at the time of injury and during follow-up. Although CT remains the gold standard in blunt abdominal trauma, US continues to play an important role in assessing the traumatized spleen. This pictorial review illustrates the various ultrasonographic appearances of the traumatized spleen. Correlation with other imaging is presented and complications that occur during follow-up are described.     

Cystic neoplasms of the pancreas: new angiographic and ultrasonographic findings.

Cystic neoplasms of the pancreas (cystadenoma, cystadenocarcinoma) are rare tumors. Early diagnosis and differentiation from other pancreatic lesions are essential for appropriate management. Pancreatic angiography and gray scale ultrasonography facilitate rapid, accurate diagnosis and proper surgical therapy. In a 7 year period, eight patients were studied (one cystadenoma, seven cystadenocarcinoma); five had selective visceral angiography and six underwent abdominal ultrasonography. The ultrasonographic characteristics of these neoplasms and some new angiographic findings are presented. The sonographic findings for cystadenocarcinoma were similar to those of cystadenoma.     

Small hepatocellular carcinoma: ultrasonographic findings and histopathologic correlation

It is known that small hepatocellular carcinoma (HCCs) were usually hypoechoic at ultrasonography (US). In this study, we analyzed US findings of 42 small HCCs less than 2 cm in diameter and correlated them with histopathologic findings. US parameters were tumor size, tumor echogenecity, and morphologic features (peripheral halo, lateral shadow, posterior enhancement, and mosaic pattern), while histopathologic parameters were Edmonson grade and microscopic features (coagulation necrosis, interstitial fibrosis, fatty metamorphosis, sinusoidal dilatation, hemorrhage, encapsulation, and internal septation). One-third of HCCs was not hypoechoic. Tumor echogenecity and morphologic features were variable, regardless of tumor differentiation and microscopic features. In our study, it seemed that US detected histopathologic changes in small HCCs more frequently than previously known, but none of these US findings could suggest a specific histopathologic finding in small HCCs less than 2 cm in diameter.     

Scintigraphic evaluation of experimental chronic osteomyelitis.

Assessment of disease activity and disease extent in chronic osteomyelitis remains a difficult diagnostic problem. Radiography is not particularly sensitive. Scintigraphic techniques can be more helpful, but the routinely available agents lack specificity (99mTc-methylene diphosphonate [MDP], 67Ga-citrate) or are laborious to prepare (111In-leukocytes). We evaluated the performance of 2 new radiopharmaceuticals, 99mTc-polyethyleneglycol (PEG) liposomes and 99mTc-hydrazinonicotinamide (HYNIC)-immunoglobulin G (IgG), in an experimental model of chronic osteomyelitis. Methods: Chronic osteomyelitis was induced in rabbits by inserting S. aureus into the right reamed and washed femoral canal. The canal was closed with cement. A sham operation was performed on the left femur. Routine radiographs were obtained immediately after surgery and before scintigraphy. Four weeks after surgery, each rabbit was injected with 37 MBq 99mTc-PEG liposomes, 99mTc-HYNIC-IgG, and 99mTc-MDP on 3 consecutive days and imaged up to 4 (MDP) or 22 (liposomes and IgG) h after injection. On day 4, rabbits received either 18 MBq 111In-granulocytes or 67Ga-citrate and were imaged up to 44 h after injection. Uptake in the infected femur was determined by drawing regions of interest. Ratios of infected-to-sham-operated femur were calculated. After the last image, the rabbits were killed, and the left and right femur were scored for microbiologic and histopathologic evidence of osteomyelitis. RESULTS: 99mTc-PEG liposomes and 99mTc-HYNIC-IgG correctly identified all 6 rabbits with osteomyelitis. 11In-granulocytes and 67Ga-citrate gave equivocal results in 1 infected rabbit. 99mTc-MDP missed 1 case of osteomyelitis. The uptake in the affected region did not differ significantly between the agents, although 99mTc-MDP tended to have higher values (MDP, 4.75 +/- 1.23 percentage injected dose per gram [%ID/g]; 67Ga, 2.05 +/- 0.54 %ID/g; granulocytes, 1.56 +/- 0.83 %ID/g; liposomes, 1.75 +/- 0.76 %ID/g, and IgG, 1.96 +/- 0.27 %ID/g). The ratios of infected-to-normal femur were also not significantly different for the respective radiopharmaceuticals. Radiography visualized only severe osteomyelitis. CONCLUSION: In this rabbit model, 99mTc-PEG liposomes and 99mTc-HYNIC-IgG performed at least as well as 111In-granulocytes and 67Ga-citrate in the localization of chronic osteomyelitis. The ease of preparation, the better image quality, and the lower radiation dose suggest that 99mTc-PEG liposomes and 99mTc-HYNIC-IgG might be suitable alternatives for 67Ga-citrate and 111In-granulocytes in the scintigraphic evaluation of osteomyelitis.     

Postnatal cranial ultrasonographic findings in feto-fetal transfusion syndrome

Our objective was a retrospective evaluation of cranial US in survivors of twin pregnancy with feto-fetal transfusion syndrome (FFTS), with knowledge of prenatal treatment and neonatal/postnatal clinical data. In 18 pregnancies with FFTS (January 1996 to May 2000), pregnancy management and outcome, and neonatal clinical/neurological data and follow-up (age of 3–7 months) were documented when available. Postnatal cranial US abnormalities were differentiated in prenatal and peri/postnatal lesions, respectively, in "donor" and "recipient." The statistical analysis used was Mann Whitney U test and Fisher's exact test. Overall pregnancy survival rate was 19 of 36 (53%); mors in utero occurred in five twin members. Gestational age at birth was significantly lower in FFTS after laser coagulation (13 of 18; p<0.05). Initial (≤4 days of age) postnatal cranial US was abnormal in 13 of 27 cases: antenatal brain lesion in 9 of 13 patients (7 of 13 donors, 2 of 14 recipients); after treatment: antenatal hemorrhage (n=6), hydrocephaly (n=1), subependymal germinolysis (n=1), lenticulostriatal vasculopathy (n=1), evidence for brain atrophy (n=2), cystic periventricular leukomalacia in<3 days (n=1); peri/postnatal brain lesions in 4 of 13 patients (hemorrhage (n=3), and periventricular leukomalacia (n=1). Finally, an abnormal brain US was found in 18 patients. Twin pregnancies complicated with FFTS are high-risk pregnancies with antenatal and postnatal mortality and morbidity. In utero cranial hemorrhage dominated the antenatal brain insults; however, pregnancy survivors remain at risk for severe peripartal and/or postnatal brain insults. Electronic Publication     

Cervical osteomyelitis due to i.v. heroin use: radiologic findings in 14 patients

We reviewed the radiographs of 14 patients who had cervical osteomyelitis and were IV heroin users. Eleven were men and three were women. Their age range was 33-48 years (mean, 39 years). Eleven regularly used the jugular vein access, and three alternated between the jugular and femoral veins. Initial radiographs of the cervical spine in 13 patients showed destruction of two or more vertebral bodies and the adjacent intervertebral disk, as well as a prevertebral soft-tissue mass. In one patient, findings on initial radiographs were normal, but marked destruction at two contiguous intervertebral levels and a large prevertebral abscess were identified 2 weeks later. All the patients had positive results on cultures of joint aspirates or bone biopsy materials (10 patients) or blood (four patients). Ten grew Staphylococcus aureus; two, Staphylococcus epidermidis; one, Streptococcus viridans; and one, Pseudomonas aeruginosa. CT in nine patients showed inflammatory reaction adjacent to the carotid sheath resulting from the repeated jugular injections and delineated the extent of prevertebral abscess and bone destruction. Scintigrams were of minimal value in establishing the diagnosis. Advanced vertebral body destruction, disk space infection, prevertebral abscess, and anterior cervical inflammatory reaction appear to be typical findings on radiographs in heroin abusers with cervical osteomyelitis.     

Spinal osteomyelitis: unusual findings on magnetic resonance imaging

In bacterial infection of the spine the intervertebral disc and its adjoining vertebral bodies are usually involved in continuity with narrowing of the disc and indistinct irregular vertebral end plates. We report a case in which the MR imaging examination demonstrated intact vertebral end plates, although the adjacent vertebral bodies and disc were involved with anaerobic streptococcus infection extensive enough to cause paravertebral inflammatory masses. Thus, intact vertebral end plates do not exclude vertebral osteomyelitis in favor of metastatic disease on MR imaging studies.     

Female paraurethral leiomyoma: ultrasonographic and magnetic resonance imaging findings

Primary benign paraurethral tumors in females are observed only rarely. They may occasionally be detected at physical examination or present with symptoms of bladder outlet obstruction. A leiomyoma originating from the smooth muscle fibers of the urethra in a 43-year-old woman is reported. The benign nature of the lesion was suspected on the basis of transvaginal ultrasonography and magnetic resonance imaging. Surgical enucleation was performed and light microscopy showed a well-differentiated smooth muscle tumor.     

Mammographic and ultrasonographic findings in bilateral breast cancer: a comparative study

To compare the results of mammographic and US examinations in unilateral and bilateral breast cancers in routine clinical work, the files of all patients with 825 preoperative mammograms and 525 preoperative US examinations operated on for primary breast cancer in the Oulu University Hospital from 1983 through 1993 were retrospectively reviewed. The only statistically significant difference noted in the mammographic findings was the false-negative rates in unilateral, bilateral and metachronous second breast cancers (6.8, 16.3 and 23.3 %, respectively). The differences were mainly due to the lower sensitivity of mammography in the detection of palpable bilateral breast cancers. The false-negative rate of US was also significantly higher in bilateral breast cancers (23 %) than in unilateral cancers (11 %), and significantly higher for nonpalpable than palpable cancers in both the bilateral and the unilateral groups. The mammographic failure rates and the difference between these two groups were most pronounced during the early study period, which underscores the importance of experience and dedicated imaging technique. The smaller tumour size at the time of diagnosis and probably the loss of the opposite breast for comparison have contributed to the higher false-negative rates in bilateral breast cancer. Received 25 April 1997; Revision received 1 September 1997; Accepted 6 October 1997