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The purposes of this study was to determine the prevalence of the accessory anterolateral talar facet (AALTF); to evaluate the relationship between AALTF, focal abutting bone marrow edema (FABME), and sinus tarsi edema; and to study the prevalence of tarsal coalitions in patients with the AALTF utilizing ankle MR images. 5-T ankle MR images were reviewed for the presence of AALTF, FABME, sinus tarsi edema, tarsal coalition, and location and type of coalition (cartilaginous, fibrous, and osseous). Multivariate analysis was performed to examine the correlation between AALTF and the other variables. Three hundred ninety-one consecutive patients were included (age range 5–86 years; mean age 45 years). An AALTF was present in 3.6% (14/391) of patients. The AALTF prevalence was 2% in women and 6.6% in men. There was a significantly association between AALTF and FABME (9/14, p < 0.05), sinus tarsi edema (13/14, p < 0.05), and tarsal coalition (4/14, p < 0.05). AALTF is relatively often detected on MRI of the ankle and significantly associated with BME, sinus tarsi edema, and subtalar coalition. Patients with a tarsal coalition should be evaluated for the concurrent presence of an AALTF.

Despite being one of the most common indications for surgery, data on the types of meniscus tear that should be treated surgically are limited. Improving patient selection requires agreement on meniscus tear description. This study evaluates a simple MRI tear classification system for inter-observer agreement. Knee MRI examinations from 57 subjects from the Osteoarthritis Initiative cohort were reviewed by two sub-specialty trained, musculoskeletal radiologists. Based on two pulse sequences, each meniscus was classified by: tear or no tear; location of tear in anterior, middle or posterior third or multiple thirds; and displaced or non-displaced radial, horizontal, longitudinal or complex tear pattern. A tear was defined as signal abnormality extending to the surface on at least two images and displacement as more than 2 mm of extrusion or separation measured orthogonal to the tear plane. Kappa, weighted Kappa and percentage agreement were calculated. For the medial meniscus, Kappa and percentage agreement estimates were, respectively: the presence of tear, 0.79 and 89.5%; tear with displacement, 0.70 (weighted Kappa) and 66.0%; tear description, 0.47 and 61.4%; tear location, 0.64 and 79.0%. For the lateral meniscus, estimates were: the presence of tear, 0.75 and 89.5%; tear with displacement, 0.81 (weighted Kappa) and 86.0%; tear description, 0.56 and 78.9%; tear location, 0.74 and 87.7%. The strength of agreement between readers was moderate to substantial underscoring the challenge of meniscus tear classification.

Intraosseous foreign body granuloma formation related to migrated surgical material is a rarely reported condition with variable imaging appearance. In this case report, we describe a foreign body granuloma that occurred in a lumbar vertebral body one level above a prior surgical fusion. The lytic appearance mimicked a skeletal metastasis in a 65-year-old patient with recently diagnosed renal cell carcinoma. To the best of our knowledge, this is the first reported case of a lumbar vertebral foreign body granuloma occurring distant from the site of surgery, indistinguishable from skeletal metastasis on radiologic examination.

A cohort of adult acquired flatfoot deformity rigid-body models was developed to investigate the effects of isolated tendon transfer with successive levels of medializing calcaneal osteotomy (MCO). Following IRB approval, six diagnosed flatfoot sufferers were subjected to magnetic resonance imaging (MRI) and their scans used to derive patient-specific models. Single-leg stance was modeled, constrained solely through physiologic joint contact, passive soft-tissue tension, extrinsic muscle force, body weight, and without assumptions of idealized mechanical joints. Surgical effect was quantified using simulated mediolateral (ML) and anteroposterior (AP) X-rays, pedobarography, soft-tissue strains, and joint contact force. Radiographic changes varied across states with the largest average improvements for the tendon transfer (TT) + 10 mm MCO state evidenced through ML and AP talo-1st metatarsal angles. Interestingly, 12 of 14 measures showed increased deformity following TT-only, though all increases disappeared with inclusion of MCO. Plantar force distributions showed medial forefoot offloading concomitant with increases laterally such that the most corrected state had 9.0% greater lateral load. Predicted alterations in spring, deltoid, and plantar fascia soft-tissue strain agreed with prior cadaveric and computational works suggesting decreased strain medially with successive surgical repair. Finally, joint contact force demonstrated consistent medial offloading concomitant with variable increases laterally. Rigid-body modeling thus offers novel advantages for the investigation of foot/ankle biomechanics not easily measured in vivo.

Several recent high-profile publications have described the dramatic growth in utilization of total knee arthroplasty (TKA) in the United States (1–4). Between 1991 and 2010, for example, the annual volume of TKA surgeries among Medicare beneficiaries increased 161.5% and per capita utilization increased 99.2% over the same period (1). Some have suggested that TKA is over-utilized (2) or that over-utilization may be one factor explaining large per capita increases in TKA surgery (1). Cram and colleagues (1) contend that recent growth in TKA utilization is likely due both to an increase in utilization of a highly effective procedure and over-utilization of a procedure that is highly reliant on subjective criteria. Any determination of the extent to which TKA surgery is appropriate or inappropriate requires the use of valid appropriateness criteria. These criteria, as applied to patients undergoing TKA, to our knowledge, have not been formally developed or studied in the US but have been developed in other countries (5–8). The most commonly recommended approach for establishing appropriateness criteria for elective surgical procedures is the RAND/UCLA method (9–11). First, a systematic literature review of risks, benefits and indications for the procedure is conducted. Second, an extensive and mutually exclusive set of clinical scenarios (typically numbering in the hundreds) are written to capture the gamut of potential patient scenarios reflecting all potentially important clinical indications. Third, an expert panel is formed to conduct a modified Delphi survey to classify each scenario as appropriate, inconclusive or inappropriate for the procedure. A rating of “appropriate” indicates the expected benefits of the procedure outweigh the expected harms to the extent that the procedure is justified. A rating of “inconclusive” indicates either that the expected benefits and harms are roughly equal or that a lack of consensus among panel members was found. An “inappropriate” rating indicates the expected harms outweigh the expected benefits. The most extensively studied RAND/UCLA-based appropriateness algorithm for TKA is the approach developed in Spain by Escobar and colleagues (5;12–15). The authors conducted a systematic review of TKA evidence related to indications, effectiveness, and risks and used this evidence to develop 624 clinical scenarios based on the following literature-based key variables: symptom behavior, functional status, extent and location of radiographic arthritis, age, knee joint mobility and stability, and prior history of surgical and non-surgical treatment. A modified Delphi survey approach was used with two independent national panels (n=11 each) of arthroplasty surgeons (n=18) and physiatrists or rheumatologists (n=4). Reliability of recommendations between the two panels was found to be high (Weighted Kappa = 0.75) for judging whether TKA for each scenario was judged to be appropriate, inappropriate or inconclusive. A subsequent study of 775 TKA patients judged as appropriate based on the appropriateness criteria (5) demonstrated the largest WOMAC Scale improvements 6 months following surgery and patients judged as inappropriate had the smallest improvements (14). Ghomrawi and colleagues contend that appropriateness criteria like those developed by Escobar and colleagues, are among the most powerful tools for improving quality of care and controlling costs (2). Because studies in other countries reported that 60% to 80% of arthroplasty procedures were found to be appropriate, Ghomrawi et al suggested that similar over-utilization in TKA was possible in the US. Given that no appropriateness criteria for TKA have been developed in the US, we used a modified version of the Escobar et al appropriateness criteria to make an initial approximation of the proportion of knee arthroplasties that may be inappropriate in the US. While the Escobar et al system was not designed for US patients, we contend that the key criteria used in the system (i.e., pain and functional status, extent of radiographic arthritis, age and knee joint impairment) are likely among the most important criteria for US patients as well (16). Our purpose was to use a modified version of the Escobar et al (5) appropriateness criteria to estimate the proportion of TKA procedures classified as appropriate, inconclusive and inappropriate. We hypothesized that the prevalence rate of TKAs judged to be inappropriate would be similar to prior reports (11;13;14) and approximate 20%.

Following IRB approval, a cohort of 3-D rigid-body computational models was created from submillimeter MRIs of clinically diagnosed Adult Acquired Flatfoot Deformity patients and employed to investigate postoperative foot/ankle function and surgical effect during single-leg stance. Models were constrained through physiologic joint contact, passive soft-tissue tension, active muscle force, full body weight, and without idealized joints. Models were validated against patient-matched controls using clinically utilized radiographic angle and distance measures and plantar force distributions in the medial forefoot, lateral forefoot, and hindfoot. Each model further predicted changes in strain for the spring ligament, deltoid ligament, and plantar fascia, as well as joint contact loads for three midfoot joints, the talonavicular, navicular-1st cuneiform, and calcaneocuboid. Radiographic agreement ranged across measures, with average absolute deviations of

Adult acquired flatfoot deformity (AAFD) is a degenerative disease resulting in malalignment of the mid- and hindfoot secondary to posterior tibial tendon dysfunction and increasing implication of ligament pathologies. Despite the complex 3D nature of AAFD, 2D radiographs are still employed to diagnose and stage the disease. Computer modeling techniques allow for accurate 3D recreations of musculoskeletal systems for the investigation of biomechanical factors contributing to disease. Following Institutional Review Board approval, the lower limbs of six diagnosed AAFD sufferers were imaged with MRI, photographs, and X-ray. Next, a radiologist graded the MRI attenuation of eight soft-tissues implicated in AAFD. Six patient-specific rigid-body models were then created and loaded according to patient weight, graded soft-tissues, and extrinsic muscles. Model function was validated using clinically relevant kinematic measures in three planes. Agreement varied depending on the measure, with average absolute deviations of

Using placebo data from a recently completed disease-modifying osteoarthritis (OA) drug trial, we seek to inform study design of future radiographic studies.Eligible patients aged ≥40 years, with body mass index (BMI) 25-40kg/m(2) and symptomatic knee OA diagnosed by modified Kellgren and Lawrence grade (KLG) 2 or 3 and pain/stiffness and/or use of medication for knee pain in the past year, were assessed by radiography using a modified Lyon-schuss (mL/S) protocol for joint space narrowing (JSN) (primary outcome variable) at baseline and weeks 48 and 96. Multifaceted quality control was conducted throughout. Repeat images were requested when the medial tibial plateau (MTP) was not aligned (inter-margin distance [IMD]1.5mm) or for other quality issues. Data are given mean ± standard deviation.Patients (74.9% female; 61.3 ± 9.1 years) had BMI 31.6 ± 4.1kg/m(2) at baseline; 222 (173 females) had KLG2, 264 (191 female) KLG3. A significant loss in joint space width (JSW) from baseline to week 48 (-0.13 ± 0.36mm) and to week 96 (-0.22 ± 0.45mm) was observed for all randomised placebo patients (p0.001 for both), and at both time points when stratified by KLG2 or KLG3. Standard deviations were small relative to mean changes, providing standardised response means for all placebo patients of 0.35 (week 48) and 0.48 (week 96).Using a tightly controlled radiographic technique, JSN is a viable outcome variable for determining disease progression in mild-to-moderate knee OA. The mL/S protocol is a sensitive and feasible method for OA studies aiming to assess rate of JSN in the knee.

There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiography is not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with falls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should be the first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspected meniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiography and MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

It is important to determine the bone mass in normal premenopausal women because increasing numbers of conditions have been identified that result in premenopausal osteoporosis. The relationship between age and bone density was evaluated in 57 carefully characterized normal, premenopausal women using both single energy quantitative computed tomography (SEQCT) and dual energy (DEQCT). The mean bone density measurements were 172 mg/ml K2HPO4 SEQCT and 185 DEQCT. Bone density showed no statistically significant decline between age 18 and age 44. Single- and dual-energy data were highly correlated with each other (r = 0.89), and dual energy appeared to confer no advantage. There was an inverse relation between density and age of menarche. Bone density did not correlate with ideal body weight, percentage fat, or subcutaneous fat area.

STUDY DESIGN: Image analysis model development.OBJECTIVE: The objective of this study was to develop a novel clinical workflow tool that uses model-based shape recognition technology to allow efficient, semiautomated detailed annotation of each vertebra between T4 and L4 on plain lateral radiographs.SUMMARY OF BACKGROUND DATA: Identification of prevalent vertebral fractures, especially when not symptomatic, has been problematic despite their importance. There is a recognized need to increase the opportunities to detect vertebral fractures so that clinically beneficial therapeutic interventions can be initiated.METHODS: Radiographs obtained from 165 subjects in the Canadian Multicenter Osteoporosis Study (CaMos) were used to construct a vertebral shape model of the vertebral column from T4 to L4 using a statistical learning technique, as well as to estimate the accuracy and precision of this automated software tool for vertebral shape analysis. Radiographs showing scoliosis greater than 15 degrees were excluded.RESULTS: Vertebral contours defined by 95 points per vertebra, represented by 79,895 points in total, were assessed on 841 individual vertebrae. The mean absolute accuracy error calculated over each vertebra in each test image was 1.06 +/- 1.2 mm. This value corresponded to an average 3.4% of vertebral height. The mean precision error, reflecting interobserver variability, per vertebra of the resulting annotations was 0.61 +/- 0.73 mm. This value corresponded to an average 2.3% of vertebral height. Accuracy and precision error estimates did not differ notably by vertebral level.CONCLUSION: The results of the current study indicate that statistical modeling can provide a robust tool for the accurate and precise semiautomated annotation of vertebral body shape from T4 to L4 in patients who do not have scoliosis greater than 15 degrees . This method may prove useful as a clinical workflow tool to aid the physician in vertebral fracture assessment and might contribute to decision-making about pharmacologic treatment of osteoporosis.

OBJECTIVE. Accurate characterization of acetabular fractures can be difficult because of the complex acetabular anatomy and the many fracture patterns. In this article, the five most common acetabular fractures are reviewed: both-column, T-shaped, transverse, transverse with posterior wall, and isolated posterior wall. Fracture patterns on radiography are correlated with CT, including multiplanar reconstruction and 3D surface rendering.CONCLUSION. In the evaluation of the five most common acetabular fractures, assessment of the obturator ring, followed by the iliopectineal and ilioischial lines and iliac wing, for fracture allows accurate classification. CT is helpful in understanding the various fracture patterns.

To prospectively compare magnetic resonance (MR) imaging-defined abnormalities of osteoarthritis (OA) of the knee with radiographic severity measurements of OA of the knee and self-reported pain.This study was approved by the institutional review board of University of Michigan. Informed consent was obtained for this HIPAA-compliant study. Knee MR imaging was performed in 117 women (mean age, 46 years; range, 32-56 years) from a community-based arthritis study (n = 1053) with 30 women in each of four categories: (a) no pain and no OA of the knee, (b) no pain and OA of the knee, (c) pain and no OA of the knee, and (d) pain and OA of the knee. OA of the knee was defined from radiographs. Two hundred thirty-two eligible knees had Kellgren-Lawrence scores for OA of the knee as follows: grade 0, 115 (49.6%); grade 1, 33 (14.2%); grade 2, 66 (28.4%); grade 3, 17 (7.3%); and grade 4, one (0.4%). MR images were assessed for location and severity of defects of cartilage, bone marrow edema (BME), osteophytes, subchondral cysts, sclerosis, meniscal and/or ligamentous tears, joint effusion, synovial cysts, and synovitis. MR imaging findings were compared with radiographic severity of OA of the knee (Kellgren-Lawrence scale) and self-reported pain with analysis of variance, t tests, and contingency table analyses.Defects of cartilage (higher than grade IIA) were found in 75% of knees; BME was found in 57% of knees (1 cm, 41%;1 cm, 16%). Large BME lesions were common in the pain and OA of the knee group (P = .001); this group was significantly more likely to have defects of cartilage (P = .001); meniscal tears (P = .001); and osteophytes, subchondral cysts, sclerosis, joint effusion, and synovitis (P.001). Defects of cartilage, osteophytes, sclerosis, meniscal or ligamentous tears, joint effusion, and synovitis were strongly related to increasing Kellgren-Lawrence grade (P.001).In middle-aged women, there were significant associations between pain, radiographic severity of OA of the knee, and seven MR imaging-identified parameters.

Six patients were retrospectively identified as having undergone lateral ligament reconstruction surgery. The surgical procedures were categorized into four groups: direct lateral ligament repair, peroneus brevis tendon rerouting, peroneus brevis tendon loop, and peroneus brevis tendon split and rerouting. At radiography and magnetic resonance (MR) imaging, the presence of one or more suture anchors in the region of the anterior talofibular ligament indicates direct ligament repair, whereas a fibular tunnel indicates peroneus brevis tendon rerouting or loop. Both ultrasonography (US) and MR imaging demonstrate rerouted tendons as part of lateral ankle reconstruction; however, MR imaging can also depict the rerouted tendon within an osseous tunnel if present, especially if T1-weighted sequences are used. Artifact from suture material may obscure the tendon at MR imaging but not at US. With both modalities, the integrity of the rerouted peroneus brevis tendon is best evaluated by following the tendon proximally from its distal attachment site, which typically remains unchanged. The rerouted tendon or portion of the tendon can then be traced proximally to its reattachment site. Familiarity with the surgical procedures most commonly used for lateral ankle ligament reconstruction, and with the imaging features of these procedures, is essential for avoiding diagnostic pitfalls and ensuring accurate assessment of the ligament reconstruction.

Objective With the use of surgical findings as the reference standard, the purpose of this study was to describe the sonographic findings of partial-thickness and complete tears of the quadriceps tendon and to determine whether sonography can potentially aid diagnosis. Methods Three hundred eighty-nine consecutive sonographic reports (January 1996 to April 2001) of the knee/quadriceps tendon were reviewed retrospectively and assessed for subsequent surgery on the quadriceps tendon. Seven cases were thus identified. Findings at surgery (complete versus partial tears) were compared with the original sonography reports. Results All 4 partial tears and 1 of 2 complete tears were diagnosed correctly on the basis of sonography. One complete tear was described as a partial tear on the basis of sonography. In a seventh case, complete disruption of the extensor mechanism with osseous avulsion of the superior pole of the patella was identified correctly. Dynamic scanning was essential in diagnosing a partial quadriceps tendon tear in 1 case. Conclusions Sonography, including the use of dynamic evaluation, was helpful in the diagnosis of partial-thickness tears of the quadriceps tendon and may aid in differentiation of such cases from complete quadriceps tendon tears, particularly in the acute setting. The presence of scar tissue in the setting of chronic injury may represent a potential pit-fall in the assessment of partial versus complete quadriceps tears. Further study is needed to define the accuracy of sonography for detecting quadriceps tendon tears.

The object of this study was to determine the effectiveness of sonography in the detection of hip joint effusions in both native and postoperative adult hips using arthrocentesis as a gold standard.Twenty-one consecutive patients with clinical suspicion of hip joint effusion were examined on sonography by one of five musculoskeletal radiologists with experience in musculoskeletal sonography. All 21 patients underwent diagnostic arthrocentesis (fluoroscopic in 16, sonographic in five) to confirm the presence or absence of joint effusion. A retrospective analysis of the sonograms was made to assess the size of the distention of the anterior joint recess (anteroposterior dimension) and the echogenicity (anechoic or other relative to muscle), and correlation was made to the presence or absence of joint effusion.Joint effusion was seen on diagnostic arthrocentesis in 10 (48%) of the 21 patients. Seven of the 21 patients had native hips and 14 had prior hip surgery. Retrospectively, no significant difference was found with regard to the size of the anterior recess distention (p = 0.34) or echogenicity (p = 0.2) when comparing the patients with and without joint effusion.Anterior recess distention and echogenicity could not reliably be used as an indicator of adult hip joint effusion, either in native or postoperative hips. Diagnostic arthrocentesis was necessary to establish or exclude the presence of hip joint effusion.

We present a case of traumatic bamboo foreign body penetration through the posterior thigh extending cephalad into the pelvis sustained during skiing. The unsuspected bamboo foreign body was missed prospectively on the initial portable trauma radiograph of the pelvis, but was retrospectively quite apparent as a linear 12 x 2-cm radiolucent region overlying the left pelvis and hip region. On CT examination, the bamboo stick appeared as a round cylindrical air-filled structure of high density compared to soft tissue - the typical appearance of bamboo. Bamboo foreign bodies can be recognized radiographically by this typical appearance, since it is one of the few wood products that causes high attenuation relative to soft tissue on CT.

The objective of our study was to sonographically characterize the dorsal aspect of the scapholunate ligament in cadaveric wrists using arthrography, MR arthrography, and anatomic correlation as the gold standard.The dorsal aspect of the scapholunate ligament in four cadaveric wrists was evaluated on sonography without knowledge of the findings from standard arthrography, MR arthrography, and anatomic sectioning. The sonographic findings were compared with the findings from other modalities. The criteria for an abnormal scapholunate ligament included an abnormal contrast communication between the radiocarpal and midcarpal joints on arthrography and a discontinuity of the dorsal aspect of the scapholunate ligament that was documented both on MR arthrography and at anatomic sectioning.Arthrography, MR arthrography, and anatomic sectioning showed the dorsal aspect of the scapholunate ligament to be normal in one specimen and abnormal in three specimens. On sonography, the normal scapholunate ligament was hyperechoic between the scaphoid and lunate bones. In the three cases of abnormality, a normal scapholunate ligament was not visualized, and an abnormal hypoechogenicity was present.The dorsal aspect of the scapholunate ligament can be depicted on sonography; abnormality is present in patients in whom the normally hyperechoic fibrillar ligament is hypoechoic or absent.

Acute megakaryocytic leukemia (AML M7) is a rare type of acute myelogenous leukemia in adults, commonly presenting with myelofibrosis. This report describes a case of a 32-yr-old male who presented with hypercalcemia and bony lytic lesions, in the absence of myelofibrosis. The diagnosis of AML M7 should be considered in a patient with pancytopenia, lytic lesions and hypercalcemia.

Background: The inherently complex three-dimensional morphology of both the pelvis and acetabulum create difficulties in accurately determining acetabular orientation. Our objectives were to develop a reliable and accurate methodology for determining three-dimensional acetabular orientation and to utilize it to describe relevant characteristics of a large population of subjects without apparent hip pathology. Methods: High-resolution computed tomography studies of 200 patients previously receiving pelvic scans for indications not related to orthopaedic conditions were selected from our institution’s database. Three-dimensional models of each osseous pelvis were generated to extract specific anatomical data sets. A novel computational method was developed to determine standard measures of three-dimensional acetabular orientation within an automatically identified anterior pelvic plane reference frame. Automatically selected points on the osseous ridge of the acetabulum were used to generate a best-fit plane for describing acetabular orientation. Results: Our method showed excellent interobserver and intraobserver agreement (an intraclass correlation coefficient [ICC] of >0.999) and achieved high levels of accuracy. A significant difference between males and females in both anteversion (average, 3.5°; 95% confidence interval [CI], 1.9° to 5.1° across all angular definitions; p < 0.0001) and inclination (1.4°; 95% CI, 0.6° to 2.3° for anatomic angular definition; p < 0.002) was observed. Intrapatient asymmetry in anatomic measures showed bilateral differences in anteversion (maximum, 12.1°) and in inclination (maximum, 10.9°). Conclusions: Significant differences in acetabular orientation between the sexes can be detected only with accurate measurements that account for the entire acetabulum. While a wide range of interpatient acetabular orientations was observed, the majority of subjects had acetabula that were relatively symmetrical in both inclination and anteversion. Clinical Relevance: A highly accurate and reproducible method for determining the orientation of the acetabulum’s aperture will benefit both surgeons and patients, by further refining the distinctions between normal and abnormal hip characteristics. Enhanced understanding of the acetabulum could be useful in the diagnostic, planning, and execution stages for surgical procedures of the hip or in advancing the design of new implant systems.

SummaryMonoclonal antibodies that bind and inhibit nerve growth factor (NGF) have demonstrated both, good analgesic efficacy and improvement in function in patients with osteoarthritis (OA). Despite initial promising data, trials in OA had been suspended by the Federal Food and Drug Administration (FDA) due to concerns over accelerated rates of OA progression. Imaging will play a crucial role in future clinical trials to define eligibility of potential participants and to monitor safety during the course of these studies. This will require baseline and frequent follow-up radiographs of both, the index joints and other large weight bearing joints to identify subjects at risk prior inclusion and on study so treatment can be discontinued.This imaging overview in the form of an atlas describes and illustrates potential exclusionary joint imaging findings at eligibility and potential adverse joint events on radiography and magnetic resonance imaging (MRI) in studies investigating a-NGF compounds. The overarching goal of this atlas is to facilitate trial design and to promote a common language and understanding between potential expert readers. This first section of the atlas will focus on knee joint specific findings that are relevant to a-NGF studies.

The radiologic work-up of shoulder pain in the aging athlete should be tailored to meet the needs and expectations of the patient and physician. The value of high quality plain radiographs cannot be over-emphasized. When a more sophisticated imagine is necessary, the choice between arthrography, ultrasound, or MRI imaging is not straightforward. Arthrography is an excellent test to demonstrate full rotator cuff tears. In competitive athletes, a more sophisticated look at the rotator cuff and adjacent structures may be desired, which can be satisfied by MR imaging.

Rapid, thorough and cost effective radiologic evaluation of the traumatized spine can be performed through a tailored sequential approach. The radiologic evaluation is performed in conjunction with clinical management, and therefore communication between clinical and radiological services is essential. Judicious use of CT and MRI can provide critical information, particularly in the symptomatic patient with 'normal' radiographs.

1711 usculoskeletal sonography can be a reliable, expedient, and readily accessible alternative to other, more costly, imaging techniques such as MR imaging. Sonography is adaptable to many situations and is not restricted by regimented standardized protocols. The sonographer interacts directly with the patient, allowing flexibility in performing the examination and often resulting in greater diagnostic effectiveness. This is particularly useful for evaluating musculoskeletal masses and infection, or for performing sonographically guided interventions.

Neurofibromas are the most common tumors of the peripheral nerves. They may be solitary lesions, multiple localized lesions, or large plexiform masses often associated with neurofibromatosis. Relatively few reports discuss the sonographic features of PNST, specifically neurofibromas.1–7 The typical sonographic description is that of a well defined, homogeneous hypoechoic lesion, which can show posterior acoustic enhancement mimicking a cystic lesion.1,3,4 We present a case of neurofibromatosis in a 19 year old man, which was initially diagnosed by ultrasonography. We describe the ultrasonographic findings that we believe correspond to the so-called target sign on T2-weighted MR imaging examinations. The appearance on T2-weighted MR images is reported as increased signal intensity peripherally and decreased signal intensity centrally.8–10 A target sign appearance was seen sonographically in numerous lesions, demonstrating a hyperechoic central region and a hypoechoic periphery.

s / Osteoarthritis and Cartilage 23 (2015) A82eA416 A360 eligibility and safety findings relevant for aNGF clinical trials. More than 400 images were reviewed to define the most relevant and characteristic imaging findings. Diagnoses of exclusion for eligibility due to potentially increased risk of RPOA are subchondral insufficiency fractures (SIF), atrophic OA and severe malalignment of the knee in the medial-lateral direction. Diagnoses relevant for safety after enrolment (i.e. joint safety findings), i.e. RPOA, SIF, osteonecrosis and pathologic fractures will also be discussed. Several of these diagnoses have non-specific findings on the radiograph or cannot be detected radiographically in early stages. Thus, in cases of inconclusive or suspicious radiography, an additional MRI examination may be acquired to rule out or confirm some of these diagnoses. Results: Early and late signs of diagnoses relevant for eligibility will be presented. Fig 3A. Radiograph of the hip joint shows superior JSN (arrows) without relevant osteophytes present. Fig 3B. Follow up image 12 months later shows near-complete destruction of the femoral head (arrows) and subsequent migration of the femur superiorly consistent with RPOA. Conclusions: Expert readers in aNGF programs need to be aware of relevant imaging findings. These include early signs of diagnoses relevant for RPOA on radiography, and other potential X-ray and MRI diagnoses relevant for eligibility and safety during aNGF studies. 591 PROLONGED JOINT RESIDENCY OF TRIAMCINOLONE ACETONIDE AFTER AN INTRA-ARTICULAR INJECTION OF FX006, A SUSTAINED RELEASE FORMULATION FOR THE TREATMENT OF OSTEOARTHRITIS N. Bodick y, J. Lufkin y, C. Willwerth y, J. Hauben y, A. Kumar y, P. Boen y, J. Bolognese z, C. Schoonmaker z, M. Clayman y. y Flexion Therapeutics, Burlington, MA, USA; zCytel Inc, Cambridge, MA, USA Purpose: Although available intra-articular (IA) corticosteroids are well established in the treatment of painful osteoarthritis (OA), limitations include short duration of pain relief (1-4 weeks), an effect consistent with the transient residency of these compounds in the joint and high plasma corticosteroid concentrations immediately following injection. FX006 is a novel IA sustained-release injectable formulation of 25% triamcinolone acetonide (TCA) in poly(lactic-co-glycolic acid) microspheres intended to prolong therapeutic concentrations of TCA in the joint and limit systemic exposure. In a previously described 6-week long clinical study, FX006 at 40 mg demonstrated maintenance of synovial concentrations of TCA consistent with pharmacologic activity for a period of at least 6 weeks, when levels of TCA produced by an equivalent dose of TCA IR were below the limit of quantitation. The current study extended these data on joint residency by measuring synovial fluid levels of TCA at later time points. Methods: In this multi-center, open-label study, patients with OA of the knee received a single IA injection of FX006 containing 10 or 40mg TCA, or 40mg of a standard, immediate-release suspension of TCA (TCA IR). A total of 50 patients were enrolled (FX006 10 mg: 10 patients, FX006 40 mg: 30 patients, TCA IR: 10 patients). Synovial fluid and plasma samples were obtained at baseline (pre-dose) and at the planned Final Visit at either Week 12, 16, or 20, depending on cohort assignment and availability of fluid in the knee. Concentrations of TCA were measured in plasma or in filtered synovial fluid samples using High Performance Liquid Chromatographic methods with Tandem Mass Spectrometry Detection and Automated Extraction, validated for the determination of TCA in human plasma and synovial fluid respectively. The quantitation limits of both assays were 50 to 50000 pg/mL. Results: In the FX006 10 mg group, 8 patients had synovial fluid available for analysis at Week 12. In the FX006 40 mg group, 6 patients had synovial fluid available for analysis at Week 12, 8 patients at Week 16 and 11 patients at Week 20. In the TCA IR group, 5 patients had synovial fluid available for analysis at Week 12. The concentrations of TCA achieved by 40mg FX006 in the synovial fluid atWeek 12 were 924 pg/mL, at Week 16, the IA concentrations of TCAwere 224 pg/mL and by Week 20 they were below the lower limit of quantitation (Figure; geometric means from the earlier 6-week study and the current study are merged). The IA concentration of TCA in patients receiving 40 mg of TCA IR at Week 12 was below the lower limit of quantitation. FX006 maintained a gradient between synovial and systemic plasma concentrations of TCA for 16 weeks.

Adult acquired flatfoot deformity is a degenerative disease causing medial arch dysfunction. Surgical correction has typically involved tendon reconstruction with calcaneal osteotomy; however, the postoperative changes have not been fully characterized. The present study assessed the success of surgical correction of Stage IIb adult acquired flatfoot deformity through changes in plantar pressures and patient-generated outcome scores. With Institutional Review Board approval, 6 participants were evaluated before and after surgery using pedobarography, the Foot and Ankle Outcome Score, and the Medical Outcomes Study 36-item short-form questionnaire. The plantar pressures were recorded using a TekScan HRMat during walking and in a 1- and 2-foot stance. The resulting contour maps were segmented into 9 regions, with the peak pressure, normalized force, and arch index calculated. Surgical effects were analyzed using paired t tests. Postoperatively, the Foot and Ankle Outcome Score and Medical Outcomes Study 36-item short-form questionnaire scores increased significantly from 180 � 78 to 360 � 136 (p < .03) and 47 � 18 to 71 � 19 (p ¼ .06), respectively. During the 2-foot stance, the normalized force had increased significantly in the lateral midfoot (p < .03), although no significant differences were found in peak pressures. No significant differences were observed in the 1-foot stance. During walking, the normalized force increased significantly in the lateral midand forefoot (p < .05). The peak pressure increased significantly in the lateral forefoot (p < .01). The arch index values demonstrated no significant changes. The increased questionnaire scores indicated that surgical correction improved the self-perceived health of the participants. Lateral shifts in the peak pressure and normalized force suggest that forefoot and midfoot loading is altered postoperatively, consistent with the goal of offloading the dysfunctional arch. Thus, the present study has demonstrated that surgical treatment of adult acquired flatfoot deformity can be accurately assessed using patient-reported outcome measures and plantar pressures.

Adult Acquired Flatfoot Deformity (AAFD) is a degenerative disease characterized by chronic changes in the joint alignment of the bones of the foot leading to significant pain and dysfunction. The hallmark of this disease is the functional loss in posterior tibialis tendon (PTT) strength though mechanical degradation of passive support structures of the foot have also been implicated, namely the spring ligament, talocalcaneal interosseous ligaments, fibers of the anterior deltoid, and the long and short plantar ligaments. [1] Clinically, AAFD patients present with midfoot collapse, forefoot abduction, and valgus tilting of the hindfoot and the magnitudes of these deformities are most often graded using plane radiographs in the mediolateral (ML), oblique anteroposterior (AP) and posteroanterior (PA) views. [1–3] The objective of this study was to develop a population of patient-matched rigid-body kinematic models using a standardized methodology that can be used to predict pathologic foot function with agreement between patient and model assessed through clinically relevant radiographic joint angles.Copyright © 2013 by ASME

This article reviews the current status of the imaging of the glenoid labrum and associated structures, including anatomic variants and the different types of labral disease.

Adult acquired flatfoot deformity (AAFD) is a degenerative disease resulting in malalignment of the mid- and hindfoot secondary to posterior tibial tendon dysfunction and increasing implication of ligament pathologies. Despite the complex 3D nature of AAFD, 2D radiographs are still employed to diagnose and stage the disease. Computer modeling techniques allow for accurate 3D recreations of musculoskeletal systems for the investigation of biomechanical factors contributing to disease. Following Institutional Review Board approval, the lower limbs of six diagnosed AAFD sufferers were imaged with MRI, photographs, and X-ray. Next, a radiologist graded the MRI attenuation of eight soft-tissues implicated in AAFD. Six patient-specific rigid-body models were then created and loaded according to patient weight, graded soft-tissues, and extrinsic muscles. Model function was validated using clinically relevant kinematic measures in three planes. Agreement varied depending on the measure, with average absolute deviations of7° for angles and4 mm for distances. Additionally, the clinically favored AP talonavicular coverage angle, ML talo-1st metatarsal angle, and ML 1st cuneiform height showed strong correlations of R(2) = 0.63, 0.75, and 0.85, respectively. Thus, computer modeling offers a promising methodology for the non-invasive investigation of in vivo kinematic behavior in pathologic feet and, once validated, may further be used to investigate biomechanical parameters that are difficult to measure clinically.

Objective To determine if inhibition of inducible nitric oxide synthase (iNOS) with cindunistat hydrochloride maleate slows progression of osteoarthritis (OA) Methods This 2-year, multinational, double-blind, placebo-controlled trial enrolled patients with symptomatic knee OA (Kellgren and Lawrence Grade (KLG) 2 or 3). Standard OA therapies were permitted throughout. Patients were randomly assigned to cindunistat (50 or 200 mg/day) or placebo. Randomisation was stratified by KLG. Radiographs to assess joint space narrowing (JSN) were acquired using the modified Lyon-schuss protocol at baseline, week 48 and 96. Results Of 1457 patients (50 mg/day, n=485; 200 mg/day, n=486; placebo, n=486), 1048 (71.9%) completed the study. Patients were predominantly women; 56% had KLG3. The primary analysis did not demonstrate superiority of cindunistat versus placebo for rate of change in JSN. In KLG2 patients, JSN after 48 weeks was lower with cindunistat 50 mg/day versus placebo (p=0.032). Least-squares mean±SE JSN with cindunistat 50 mg/day ( −0.048±0.028 mm) and 200 mg/day (−0.062±0.028 mm) were 59.9% (95% CI 6.8% to 106.9%) and 48.7% (95% CI -8.4% to 93.9%) of placebo, improvement was not maintained at 96 weeks. No improvement was observed for KLG3 patients at either time-point. Cindunistat did not improve joint pain or function, but was generally well tolerated. Conclusions Cindunistat (50 or 200 mg/day) did not slow the rate of JSN versus placebo. After 48-weeks, KLG2 patients showed less JSN; however, the improvement was not sustained at 96-weeks. iNOS inhibition did not slow OA progression in KLG3 patients. Clinical trial listing NCT00565812

Adult Acquired Flatfoot Deformity (AAFD) is a degenerative disease characterized by chronic changes in the joint alignment of the bones of the foot leading to significant pain and dysfunction. The early stages of the disease are thought to involve primarily the mechanical degradation of the soft-tissue support structures of the foot, namely the spring ligament, talocalcaneal interosseous ligaments, fibers of the anterior deltoid, and the long and short plantar ligaments, as well as a functional loss in posterior tibialis tendon (PTT) strength. [1] These changes manifest clinically as midfoot collapse, forefoot abduction, and valgus tilting hindfoot. [1–3] Various surgical corrections exist for Stage II AAFD to restore more normal biomechanical function to the foot. Treatment selection is most often based on clinical outcomes and surgeon preference. However, the optimal procedure(s) for an individual patient is unknown. Computer Aided Design (CAD) approaches offer advantages for evaluating foot function as well as the ability to predict pre-operatively the outcome of corrective procedures. This study developed a 3D patient specific computer model of the lower leg from a diagnosed Stage II flatfoot patient and evaluated its ability to predict foot function pre- and post-operatively through agreement with clinically relevant radiographic joint angles.Copyright © 2012 by ASME

A case of calcific tendinitis of the gluteus medius is presented. This report describes a patient with a history of breast cancer who had the combination of amorphous calcifications in the gluteus medius tendon and the MR finding of conspicuous bone marrow edema in the adjacent greater trochanter, prompting concern for metastatic disease. We present images from radiography, bone scanning, CT, and MR imaging. The unusual combination of findings in these studies should be considered conclusive for calcific tendinitis, and should not be confused with malignancy.

The bone marrow edema (BME) pattern of signal intensity changes on magnetic resonance (MR) images (decreased on T1-weighted and increased on T2-weighted) is a nonspecific finding encountered with several entities, including transient osteoporosis of the hip, transient BME syndrome, osteonecrosis, trauma, infection, and infiltrative neoplasm. Transient osteoporosis, an unusual but distinct syndrome characterized by self-limited pain and radiographically evident osteopenia, can be distinguished from other causes of the BME pattern, particularly osteonecrosis, on the basis of clinical findings and the development of radiographically evident focal osteopenia within 8 weeks after the onset of pain. This is an important distinction, since all patients with transient osteoporosis recover completely, without intervention. The term transient BME syndrome can be used to describe any patient in whom a reversible BME pattern is seen on MR images. Although the transient BME syndrome is also self-limited and quite likely related to transient osteoporosis, the authors believe that to avoid confusion, this nonspecific term should be reserved only for patients who do not develop radiographically evident osteopenia.

The seat belt syndrome consists of skeletal, soft-tissue, and visceral injuries associated with use of two- and three-point restraints in patients involved in motor vehicle accidents. Skin abrasions of the neck, chest, and abdomen--the classic seat belt sign--indicate internal injury in 30% of cases. Neck abrasions are associated with injuries to the carotid artery, larynx, and cervical spine; chest abrasions, with fractures of the sternum, ribs, and clavicles and injuries to the heart and thoracic aorta; and abdominal abrasions, with mesenteric tears, bowel perforation and hematoma, Chance fractures, and injuries to the abdominal aorta. The seat belt sign should prompt a diligent search for related injuries.