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Diffuse idiopathic skeletal hyperostosis (DISH) is a disorder characterized by bone proliferation of spinal and extraspinal structures. Frequently, extraspinal manifestations may occur before the involvement of the spine. These alterations are so common and characteristic that they should be included in the diagnostic criteria for DISH. The patella is one of the most commonly involved sites. The knee of 48 patients affected by DISH, according to Resnick's diagnostic criteria, were subjected to systematic, radiographic and xerographic studies. The most characteristic radiographic patterns are: thickening of the anterior margin of the patella (81.1%); ossifying enthesopathy of supero-anterior margin of patella (68.7%); periosteal new bone formation on the tibial insertion of the cruciate ligaments (47.8%); presence of fabella (41.%); presence of megafabella (22.9%), which may come near the posterior profile of the femur. Changes are usually symmetrical in DISH: entheseal abnormalities mostly involve the antero-superior margin of the patella, whereas in osteoarthritis, osteophytes are found on the postero-superior margin. In the lateral view enthesophytes at the bone attachment of the cruciate ligaments are oriented inside the joint space; on the contrary, osteophytes are always oriented outside the joint space. Radiographic manifestations of the fabella are similar to those observed in osteoarthritis, and so they cannot be utilized in the differential diagnosis of these diseases.

The authors have used in 100 cholecystopathic patients xeroradiography of oral opacified gallbladder. This method is, however, considered a complementary one. Undoubtedly, it enabled a differential diagnosis between lacunae due to radiolucent calculi and gaseous pseudo-lacunae.

Alkaptonuria is a rare autosomal recessive metabolic disease, due to the lack of homogentisic acid oxidase. The following accumulation of homogentisic acid brings about a black discoloration of both the urine (alkaptonuria) and connective tissue (ochronosis). The ochronotic alterations into joint cartilages cause degenerative arthropathy and osteopenia. The radiological features of three unrelated cases of alkaptonuria are reported. Radiographic abnormalities of ochronotic arthropathy are found in both the spine and the extraspinal joints. In the spine, the progressive calcification and "vacuum" phenomenon of disc spaces are the most characteristic findings. Disc space narrowing is associated with calcification and marginal sclerosis of vertebral bodies and is accentuated by osteopenia. Osteophytes are usually absent or of small size; nevertheless progressive formation of marginal intervertebral bridges and obliteration of disc spaces at multiple levels ("pseudoblock vertebrae") may occur. In extraspinal sites, space narrowing, bone sclerosis and fragmentation may also be observed. Diagnosis of ochronotic arthropathy is often suggested by radiographs of the spine, and it is confirmed afterwards by clinical and laboratory findings. The characteristic radiological findings of ochronotic spondylitis, in the final stage, include narrowing of at least four lumbar disc spaces, associated with their calcification and "vacuum" phenomenon, "pseudoblock vertebrae", marginal sclerosis and osteopenia of vertebral bodies.

99mTc-polyphosphate joint imaging of the hand has been performed in 18 patients, with evidence of inflammatory joint disease, but without any significant radiographic lesions, which might be related to rheumatoid arthritis. The hand scans were compared to clinical and radiographic data. An year after, the same subjects were re-examined, with both the radionuclide imaging and radiography. Scintigraphy has been shown to be significantly more sensitive for detecting inflammatory joint disease than x-ray, especially in the early stage of rheumatoid arthritis. Although radionuclide imaging is non specific (activity is increased also in osteoarthritis, trauma, metabolic bone disease, infarction, etc.). Radiography is highly specific but relatively non sensitive.

Radiographic features of calcium pyrophosphate dihydrate (CPPD) crystal deposition disease are outlined in an investigation of 32 patients, with definite or probable disease (according to the diagnostic criteria previously utilized by McCarty). The crystal deposits within fibro- and hyaline cartilage (chondrocalcinosis) may produce an acute synovitis (pseudogout syndrome), and in some patients a radiographically distinctive degenerative arthropathy (pyrophosphate arthropathy). These abnormalities are most frequent in the knee, wrist and symphysis pubis, but often other joints may be affected. Although the alterations superficially resemble osteoarthritis, they are more severe and progressive (Charcot-like joint).

The skull in homozygous beta-thalassemia (Cooley's anemia) may present with several abnormalities, such as osteopenia, widening of the diploic space, and a "hair on end" appearance. In some cases it presents also a particular stratified aspect owing to a variable number of osseous lamellae, arranged so as to be parallel to the inner table. This "lamellated skull" was observed in 16 patients, selected from 150 patients with Cooley's anemia (10.6%). The possible mechanisms are discussed. The pluristratified lamellar osseous production could be brought about by repeated periosteal osteoblastic reaction to the sinusoidal neovascularization associated with marrow hyperplasia in poorly or not at all transfused patients.

The authors have reviewed the radiographic patterns of the foot in 28 patients affected by neuropathic joint disease complicating alcoholism, out of a series of 82 chronic alcoholic patients. Sixteen of them were also affected by diabetes mellitus. On the basis of X-ray findings, lesions were divided into three groups, reflecting the evolution of the disease: 1) early changes, especially affecting the soft tissues and joints; 2) definite lesions, consisting of fractures, osteolysis, bone destruction and amputation, periarticular debris; 3) "healing" signs, simulating degenerative joint disease, which cause severe and weakening deformities. Tabes dorsalis and diabetic osteoarthropathy must be differentiated from alcohol-induced syndrome. Even though a correct differential diagnosis is often difficult to reach, it must be kept in mind that focal/diffuse osteopenia is the most characteristic manifestation of alcoholic osteopathy, whereas different radiographic findings simulate chronic degenerative arthropathies.

The first classic description of so-called "spade hand" in acromegaly dates from 1886 and is reported by Marie [22]. The hand radiograph is easily diagnostic, when gross abnormalities are present. Sometimes, however, it may be difficult to distinguish the appearances of the milder case from the normal, only by X-ray. The aim of this paper is to define the position of several hand measurements (sesamoid index, tufting, joint space thickness, hand length, metacarpal index, soft tissue measurements at index finger) and to compare these indices in relation to the detection of disease in radiological diagnosis. Hand measurements were made in 100 normal controls and in 19 cases of acromegaly, of whom hand radiograph and xerograph were performed and also compared each others.

Radiographs and xerographs of the hands of 35 patients with progressive systemic sclerosis (PSS), as defined by the ARA, were reviewed. Patients with "overlap" syndromes (i.e., mixed connective tissue disease, systemic lupus erythematosus or rheumatoid arthritis) have been excluded. Soft tissue changes included atrophy (hide-bound skin), and dystrophic calcifications, particularly in CREST patients (calcinosis, Raynaud phenomenon, esophageal dysmobility, sclerodactily and telangectasia). The most common bony change is resorption of distal phalanges; diffuse osteoporosis is also frequent; the distal interphalangeal and first carpometacarpal joints involvement appear as a distinctive feature of this erosive arthritis.

Basic calcium phosphate (BCP) crystal deposition can lead to periarticular collections associated with typical radiographic findings, most frequently observed in the shoulder. Moreover, these deposits may be revealed in other articular sites (i.e., wrist, hand, foot, elbow, hip, etc.). Initially, the calcium deposits may appear poorly defined (cloudlike); afterwards, they may reveal different patterns (linear, triangular or circular areas), changing in size, configuration and site. Adjacent bone may be normal, although osteoporosis, cystic lesions and reactive sclerosis are reported. The radiographic appearance of calcifications will depend upon the exact location of the deposits in the specific tendon of the rotator cuff, the adjacent bursae and the soft tissues.

The radiographic patterns of the skeleton of 73 patients affected by multiple myeloma (MM) were compared to the correspondent scintigraphic findings. Whole body scans were performed using 99m Tc-diphosphonates (bone scintigraphy), and 99m Tc-microcolloids (bone marrow scintigraphy). The results indicate that: a) radiography is more sensitive and accurate than scintigraphy in detecting typical myeloma-related bone lesions; b) bone scintigraphy is useful in detecting alterations in particular locations--i.e., sternum, ribs, scapulae, etc.--which are difficult to demonstrate by plain X-rays; moreover, the recovery of the fractures can be visualized; c) bone marrow scintigraphy is employed to demonstrate the presence of marrow expansion, of cold/hot spots, and relative marrow uptake, related to phagocytic activity. Since in adult men red marrow is confined to the epiphysis of long bones and to the spine, all the diseases affecting bone marrow cause medullary expansion/reduction, which are both easily detected by specific radiopharmaceuticals. The peripheral expansion is clearly documented especially in distal humeri and femora since marrow uptake is included, in healthy adults, in the axial and proximal appendicular skeleton. In spite of its yielding unique information, bone marrow scintigraphy remains an additional technique of bone scan, because of its low diagnostic accuracy.

Radiographs of the hand of 53 patients with diffuse idiopathic skeletal hyperostosis (DISH) were compared with 20 acromegalic subjects and 100 matched controls. Bone qualitative changes, characteristic of DISH, include: (1) arrow-heading of the distal phalangeal tufts; (2) enthesopathy of the proximal phalanges; (3) enlarged sesamoid bones; (4) hook-like exostoses at the metacarpophalangeal heads; (5) cortical thickness of diaphyseal tubular bones. Therefore, the hand in this disease appears as a "robust" form, particularly in males, resembling acromegalic pattern, but in this disease, the hand is much more coarse (so called squared hand), especially because of the soft tissue involvement and articular cartilaginous hypertrophy. Only enthesopathy seems to be the most characteristic and peculiar finding of the disease. Quantitative bone change measurements have demonstrated in DISH that metacarpal and Exton Smith indices differ statistically toward the controls. The hand is wider, but in males bone mass may result the same and in female is shortly reduced. Soft tissue alterations, compared with the controls, are not significant. On the contrary, in acromegaly there is a significant statistical difference in all the quantitative measurements of both the skeletal and soft tissue lesions, compared with the controls and patients affected by DISH.

The incidence of aseptic necrosis of femoral head in homozygous beta-thalassaemia (Cooley's anaemia)--which is indeed significantly high--is not satisfactorily referred in late literature regarding haemolytic syndromes. Therefore, 4 cases of osteonecrosis of femoral head, recently recognized in a series of 280 patients affected by Cooley's anaemia (14.5 0/00) are presented, and a review of hypotheses about the pathogenesis of the lesions is considered. In Cooley's anaemia, the skeletal lesion (osteoporosis) must be believed as a propitious state, in which some other pathogenetic events (i.e. local ischemia, bony age, etc.) and microtraumas overlap. In any case, characteristic blood circulation of the femoral head is the "conditio sine qua non" in developing osteonecrosis.

Skull X-rays of 60 patients with chronic renal failure were examined. Alterations included diminished or increased bone density, radiolucent areas, pepper pot skull and the disappearance of vascular grooves and sutures. It is suggested that the radiological aspect of the skull is of very little diagnostic use in the assessment of uremic osteopathy since specific alterations are rare and tardive and show no correlation with clinical and laboratory findings. Skull X-rays can be useful in assessing the effects of treatment (vitamin D derivatives, parathyroidectomy) and for the identification of focal lesions (brown tumors).

Plain films and direct magnification radiographs of the hands were performed in 34 patients affected by rheumatoid arthritis, using mammographic x-ray tube, achieved with 0.1 mm microfocus, and 1.85 X magnification factor. Direct magnification radiography has provided essential or useful diagnostic data in 44% of cases, particularly in recognizing early skeletal erosions. Nevertheless direct magnification radiography must be used only in those cases in which traditional mammographic techniques do not supply satisfactory results.

Two cases intramural pseudodiverticulosis of the oesophagus are presented. The importance of a radiological examination when studying this condition is underlined.

Erosive osteoarthritis (EOA) is a peculiar form of osteoarthritis, characterized by inflammatory destructive changes (erosions) in the interphalangeal joints, with relative sparing of the metacarpophalangeal joints, and frequent involvement of the trapeziometacarpal joint. Linear periosteal bone apposition is also commonly reported. In EOA, erosions tend to occur exclusively in the subchondral cortex of joints, causing in DIP joints a typical "gull wings" configuration of bones of distal phalanges, whereas in psoriatic arthritis (PA) and in rheumatoid arthritis (RA) the "bare areas" are primarily affected. However, such "gull wings" erosions are nonspecific, and may be observed in the late stage of PA in the IP joints, or RA in the PIP joints.

Radiological aspects of the hand are presented and discussed in connection with some of the more common systemic diseases involving the bones, in which the hand is an ideal diagnostic indicator. Suitable X-ray techniques and xeroradiography are used to identify alterations to the periostium, the bone cortex and marrow and the soft tissues. The different diseases were classified according to the part of the hand involved: a) distal extremities; b) proximal phalanges and metacarpals; c) entire hand; d) wrist area.

A tomographic investigation was performed on 51 randomly-selected rheumatic patients, according to American Rheumatism Association criteria. Fourteen males and 37 females, aged 26 to 73 (mean age 50.9) were examined in order to identify the prevalence of temporo-mandibular joint involvement. By means of a special examination form, a contemporary clinical survey of both signs and symptoms of mandibular dysfunction was also conducted: the data were used for calculating the Helkimo anamnestic and clinical dysfunction indices. As for X-ray diagnosis, and original linear and angular analysis was proposed to measure the relationship between condyle and fossa in intercuspal position and during opening: the anterior joint space often increased and protrusive condylar path was reduced in more than 41% of patients. Structural changes were also evaluated by classifying the shape of both the condyle and the glenoid fossa (rounded, wedge-shaped and flattened). A special score was used to quantify these morphological features: only 4% of the whole of joints resulted uninjured. The most involved joint portions were the articular tubercle and the anterior condylar pole. Many cases were demonstrated of marked resorption and remodelling of the condyle, of increased joint space and erosion of the fossa; in other instances, reduced joint spaces and sclerosis were observed, depending on associated degenerative arthritis (usually more painful). Sex and age differences were not significant. Severity of clinical dysfunction and seriousness of the lesions coincided, whereas subjective symptoms were relatively independent. At any rate, the survey demonstrated a clear prevalence of structural, as well as functional, involvement of the temporo-mandibular joint in rheumatoid arthritis and suggested a more careful and multimodal therapeutic approach.

The authors emphasize the value of mammography with a 0.3 millimetres microfocus-tube with a magnification system. This technique is limited to those large lesions increasing "twilight effect". For a better study of all breast's lesions the use of fine microfocus-tubes is suggested, as it results also from the latest literature.

A xeroradiographic investigation of the skull, hand and elbow bones were carried out by the authors in 50 patients with beta-thalassemia major and in 14 with beta-thalassaemia intermedia. The results were extensively compared with x-ray images. The xeroradiographic method, for its edge contrast enhancement effect and great latitude, better documented than x-ray widening of the medullary cavities and cortex thinness in the shaft of long bones. The diploic space of the skull appeared more detailed; the "hair-brush" pattern and outer table were also particularly demonstrated. The use of "positive mode" imaging is the main requirement in the study of skull and extremities. The changes observed with xeroradiography were statistically more characterized than that seen with x-ray, enhancing the evolution of bone involvement due to actual longer survival of these patients.

Clinical, radiological and ultrasonographical features of three cases of xanthogranulomatous pyelonephritis, one of which in a child, are reported. Presurgical diagnosis of xanthogranulomatous pyelonephritis is difficult and infrequent to date (10-14% of cases according to different workers). This complaint is generally mistaken for other types of kidney infections or tumours. The use of ultrasonography and computed tomography in particular help recognition of the disease and above all help to assess its extra-renal spread: something that has only recently been made possible.

A detailed examination of the hands and feet was performed in a group of 34 patients affected by systemic lupus erythematosus (SLE), using low-dose mammographic film and Rank Xerox selenium plate, according to current diagnostic techniques. All patients presented articular symptoms (pain and arthralgia). The high incidence (38,8%) of patients with no radiographic evidence of bone damage-even though articular symptoms are present-is emphasized. In such cases, it is very difficult to distinguish SLE from rheumatoid arthritis, especially as far as therapeutic management and prognosis are concerned. The lack of any "pathognomonic" radiological sign of the lupus arthritis, in the hands as well as in the feet, is then stressed. Nevertheless, arthropathy in SLE is defined as a deforming non-erosive arthritis, with a typical symmetric distribution, affecting most commonly-according to incidence-the proximal interphalangeal and metacarpophalangeal joints. In the hand, arthropathy is referred to as Jaccoud's type arthritis, because it is characterized by joint deformities which can be corrected. In the foot, the main abnormalities include hallux valgus, subluxation of the metatarsophalangeal joints and widening of the forefoot.

The term "enthesis" designates the sites of tendon, ligament and articular capsule insertion to bone. Entheses are fundamental to the cybernetic regulation and correlation of postural and motion functions in the body. They also hold a key position in the locomotor system diseases. "Enthesopathy" is a disease occurring at these sites (primary enthesopathy), which can occur alone or together with different disorders, including inflammatory, degenerative, metabolic and traumatic conditions (secondary enthesopathy). Enthesopathy may lead to articular and non-articular manifestations: common sites of involvement include the spine and pelvis, femoral trochanter, humeral tuberosity, patella, olecranon and calcaneus. In acute enthesopathy, all the signs of acute inflammation may be present. In subacute or chronic forms, pain and tenderness localized in the entheses are found. Radiographic patterns include bone erosion, hyperostosis (enthesophytes), bone fragmentation and crystal deposits.

A case of Mönckeberg's arteriosclerosis associated with Raynaud's phenomenon and diabetes is reported. It is probable that Mönckeberg's arteriosclerosis could provoke a Raynaud's phenomenon when predisposing local conditions, such as microvasculature and/or haemorheological alterations, are present. Finally our findings seem to demonstrate that xeroradiographic investigation is most important for the early diagnosis of the disease.

Calcium pyrophosphate dihydrate crystal deposition disease is a clinical condition characterised by Gout-like synovitis (pseudogout), calcification on and around the joints and an arthropathy that is radiologically similar to osteoarthritis (chronic pyrophosphate arthropathy). Though all these radiological clinical aspects may coexist in the same patient this is often not the case. An examination of the X-ray data on the 68 cases studied which were diagnosed on the basis of the criteria proposed by McCarty, shows that the disease is relatively common especially in the over-fifties. When chronic pyrophosphate arthropathy is the only clinical manifestation of the disease differential diagnosis from the osteoarthrosis so common in the elderly is difficult and depends on the greater severity and progression of the joint damage that may often affect joints not subjected to weight such as the shoulder, unlike what happens in osteoarthritis.