My Thesis in 3 Minutes

MyT3 5 - Musculoskeletal

Lectures

1
MyT3 5 - Diffusion-weighted magnetic resonance imaging of the normal bone marrow in children and the effects of local and systemic cancer therapies

MyT3 5 - Diffusion-weighted magnetic resonance imaging of the normal bone marrow in children and the effects of local and systemic cancer therapies

03:01E. Pace, London / UK

Purpose:

To establish apparent diffusion coefficient (ADC) values for normal paediatric clival marrow and variation with age, gender, and puberty. To compare post-photon and proton-therapy clival ADC changes. To examine chemotherapy effects on ADC in the spine. To develop a longitudinal study to assess post-transplant bone marrow changes.

Methods and materials:

Inclusion criteria: 5-17 years old, iso-DW-MRI ISO, non-oncological population (aim 1). Exclusion criteria: drugs (aim 1), dental brace, DW-MRI artefacts. Image acquisition/analysis: 1.5 T scanner. DWI with b = 0 and 1000 s/mm2. A 4-6 mm region-of-interest drawn within the clivus (Adept®, The Institute of Cancer Research) and at L3-S1. ADC calculated on a voxel-by-voxel basis through a monoexponential fit of the data yielded mean, median, 10th, 25th, 75th, and 90th centile ADC values.

Results:

With chemotherapy, a reduction in vertebral ADC at 3 months was stabilised or decreased by 6 months. Although no oedematous response developed, fat replacement of haematopoetic tissue still resulted.

Conclusion:

As paediatric prospective studies to investigate normal bone marrow are ethically difficult, the work in this thesis was largely retrospective. A first innovative attempt to establish the influence of age, gender and puberty on ADC values of clival marrow in cancer-free children alongside an assessment of oncological local and systemic treatment-related effects have been made.

Limitations:

Unnumerous cohorts. Non-standardised acquisition timing of the follow-up scans; different tumour types, photon/proton dose, and chemotherapy. PUMA (Paediatric osseoUs Marrow Assessment) trial recruitment still in progress.

Ethics committee approval

Service Evaluations (562 and 756) approved by The Marsden. Approval from the Joint Research Committee to import MR scans performed at St George’s Hospital. PUMA trial approved by the Health Research Authority.

Funding:

Cancer Research United Kingdom grant (2013-2018).

2
MyT3 5 - Application of "Trigger Drop" in patients enrolled for percutaneous treatment of symptomatic discal hernia: preliminary results

MyT3 5 - Application of "Trigger Drop" in patients enrolled for percutaneous treatment of symptomatic discal hernia: preliminary results

03:09Z. Falaschi, Novara / IT

Purpose:

Trigger drop® is a muscle mediator that reduces the pain due to articular and muscular etiology. The device acts on crossed muscular chains and on neuro-lymphatic points with antalgic effect. We performed “dropping technique” applying inherit devices with different shapes in different positions on the body surface.

Methods and materials:

From January to June 2019, 19 symptomatic patients have been enrolled. All patients were candidates to either cervical (5 patients) or lumbar (14 patients) disc treatment. Primary and secondary endpoints have been evaluated: efficacy of Trigger-Drop® has been evaluated in stopping analgesic drugs assumption and reducing back-pain through the visual analogic scale (VAS) evaluated before and soon after the device positioning. We performed a clinical follow-up three weeks after Trigger-drop positioning.

Results:

In 89,5% (17 Patients) the device had immediate pain relief with a VAS reduction >4 compared to the initial value. 87.5% of patients stopped painkillers therapy after the application of Trigger-Drop®. Only one minor side effect was reported (localised cutaneous erythema), which disappeared by itself.

Conclusion:

In our experience the positioning of Trigger-drop®, in patients waiting for percutaneous disc treatment, has been effective and safe in relieving back pain for a short period (three weeks), improving the overall quality of life of patients. Trigger-Drop® therapy allowed the pharmacologic therapy suspension for pain management.

Limitations:

Not a large cohort of patients included.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

3
MyT3 5 - Staging of osteochondral lesions of the talus: comparison of cone-beam CT arthrography with MR imaging

MyT3 5 - Staging of osteochondral lesions of the talus: comparison of cone-beam CT arthrography with MR imaging

03:03J. Desimpel, Edegem / BE

Purpose:

An osteochondral lesion (OCL) is defined as damage involving both articular cartilage and subchondral bone. OCL of the talus is frequently detected by routine MRI by identification of bone marrow oedema as an indirect marker of overlying cartilage lesion. The articular cartilage of the talus and the distal tibia is thin compared to the knee joint hampering precise staging of osteochondral lesions of the talus on MRI. CBCT-arthrography has a better spatial resolution than MRI and visualises the articular cartilage more in detail. The purpose of this study was to compare the value of CBCT-arthrography as staging method of talar OCL.

Methods and materials:

35 patients with a talar OCL underwent both MR imaging (1.5T) and CBCT-arthrography within a time frame of maximum 1 month to avoid significant lesion progression between both examinations. The following parameters were scored individually by two radiologists: depth of the cartilage lesion, degree of detachment (no, partial or complete), size and the presence of subchondral bone changes.

Results:

CBCT-arthrography led to an upstaging of the OCL in 28 cases. 13 patients subsequently underwent surgery of which 6 patients had an upstaging of the degree of detachment on CBCT-arthrography (upstaging to partial detachment in 2 cases and to complete detachment in 4 cases). Surgery was recommended in 3 cases of which 2 patients had an upstaging of the degree of detachment on CBCT-arthrography (1 patient with partial and 2 patients with complete detachment).

Conclusion:

CBCT-arthrography is a very promising technique for staging of cartilage lesions of the ankle. Improved staging is very useful in those clinical scenarios where arthroscopic treatment of the lesion is considered.

Limitations:

This stud is limited by the number of patients.

Ethics committee approval

Ethics committee approval.

Funding:

No funding was received for this work.

4
MyT3 5 - Diagnostic accuracy of dual-energy CT in assessment of traumatic bone marrow oedema of lower limb and its correlation with MRI

MyT3 5 - Diagnostic accuracy of dual-energy CT in assessment of traumatic bone marrow oedema of lower limb and its correlation with MRI

03:08H. Yadav, New Delhi / IN

Purpose:

To assess the diagnostic accuracy of dual-energy CT in detecting bone marrow oedema in patients of trauma of lower limb and correlate it with MRI.

Methods and materials:

The study included 40 patients aged between 15–70 years of either sex. All the patients of lower extremity trauma after clinical evaluation underwent DECT and MRI evaluation. All the images were postprocessed on a work station and were further evaluated by a radiologist.

Results:

Mean attenuation at fractured site observed by dual-energy CT was found to be significantly higher as compared to that at the adjacent site (170.75±33.99 vs 19.73±22.50 HU). Sensitivity, the specificity of dual-energy CT as compared to MRI in detecting bone marrow oedema were 94.1%, 91.3% respectively. Out of 40 cases enrolled in the study, agreement of MRI and dual-energy CT was observed in 37 (92.5%).

Conclusion:

Dual-energy CT can be an effective alternative to MRI in detection of bone marrow oedema in patients of lower limb trauma. Dual-energy CT can also be used in patients in whom MRI is contraindicated.

Limitations:

Not applicable.

Ethics committee approval

Not applicable.

Funding:

No funding was received for this work.

5
MyT3 5 - The role of bone marrow lesions in acute joint injury

MyT3 5 - The role of bone marrow lesions in acute joint injury

03:06L. Selvarajah, Limerick / IE

Purpose:

Post-traumatic osteoarthritis (PTOA) mainly affects a younger population cohort and poses significant costs to healthcare systems. Recent developments have identified that joint injury is initiated in the sub-chondral region of the joint despite the initial intra-articular cartilage injury. Of particular interest is bone marrow oedema or lesions (BMLs) that appear in the sub-chondral region almost immediately after initial joint injury.

Methods and materials:

A review is undertaken on what is known about these phenomena (microcracks and BMLs) in the literature and discuss potential mechanisms by which they may be linked. Papers published in the last 10 years relating to bone remodeling in joint injury, subchondral microdamage, BMLs, bone-cartilage crosstalk and novel imaging models demonstrating acute knee injury were reviewed.

Results:

The recent findings in this field have shown that microcracks in bone initiate targeted remodelling via RANKL expression in osteocytes. Other work has shown that subchondral microcracks co-localise with BMLs as viewed by MRI. Finally, BMLs are associated with and predict subsequent pain and structural joint degeneration.

Conclusion:

This paper demonstrates that subchondral microcracks likely occur during acute joint injury, and are closely linked to BML that are seen by clinical MRI and thus are potentially involved in the subsequent joint degeneration that occurs after injury. BMLs could serve as a potential site of radiological monitoring and therapeutic intervention to better tailor patient management.

Limitations:

The precise way in which subchondral activities are linked with those in the articular compartment is not yet known but defining these events using additional imaging sequences (DWI-ADC/T1rho) will be an important next step in this field.

Ethics committee approval

This article does not contain any studies with human or animal subjects performed by any of the authors.

Funding:

No funding was received for this work.

6
MyT3 5 - Long-term comparison between blind and ultrasound-guided injection in Morton neuroma

MyT3 5 - Long-term comparison between blind and ultrasound-guided injection in Morton neuroma

03:03F. Ruiz Santiago, Granada / ES

Purpose:

This study aims to compare the effectiveness of blind vs ultrasound-guided injections in Morton neuroma until one year of follow-up.

Methods and materials:

This is an evaluator blinded randomised trial. 31 patients with Morton neuroma were injected based on anatomic landmarks and 33 patients under ultrasound guidance. Patients were clinically assessed by the VAS score (0-10), and by the Manchester Foot Pain and Disability Index (MFPDI) –17 items; total score: 17 (best state) - 51 (worst state). Injections containing 1 ml of 2% mepivacaine and 40 mg triamcinolone were administered in the web space. Follow-up was performed at 15 days, 1 month, 45 days, 2 months, 3 months, 6 months and 1 year.

Results:

Improvement in the VAS score was superior in the ultrasound group at all points of follow-up (p<0.05) except at 1 year when differences did not reach statistical significance (VAS: 4.6 ± 0.6 vs 5.9 ± 0.6, p=0.16). The improvement according to the MFDI was superior in the ultrasound group from 45 days to one-year follow-up (31.4± 1.7 vs 36.8± 1.9, p<0.05).

Conclusion:

Ultrasound-guided injections in Morton neuroma led to greater long-term clinical improvement than blind injections. Although differences in pain tend to disappear at one-year follow-up, the disability index remains statistically improved in the ultrasound-guided group in comparison with the blind group.

Limitations:

MN was not confirmed by histological examination in all our patients, but the overall accuracy of clinical and imaging diagnosis altogether has been reported to be very high, over 95%. Another limitation of the study is the sample size, which may have prevented differences from reaching stronger statistical significance.

Ethics committee approval

The study was approved by the local ethics committee (code: 0565-N-16).

Funding:

No funding was received for this work.

7
MyT3 5 - MRI findings and their correlations in patients with symptomatic subtle cavovarus hindfoot deformity

MyT3 5 - MRI findings and their correlations in patients with symptomatic subtle cavovarus hindfoot deformity

02:56I. Menkova, Saint-Petersburg / RU

Purpose:

To find significant associations of ligamentous, tendon, osseous abnormalities in patients with symptomatic subtle cavovarus hindfoot deformity.

Methods and materials:

Ankle MRI of 35 patients (18 male; mean age 52±5,6) with clinical and radiographic evidence of subtle cavovarus hindfoot deformity was assessed by 2 musculoskeletal radiologists. Pearson's, Spearman's Rank correlation coefficients were used for analysing.

Results:

All patients with cavovarus hindfoot deformity underwent weight-bearing radiographic measurement of Cobey angle, a measurement of the modified Cobey angle on MRI. All patients were divided into the groups according to Cobey angle range. Group I: 19 patients with Cobey angle of 1-4°, group II: 10 patients - 5-9°, group III - 6 patients – >9°. Signs of peroneal tendinopathy were found in all patients. The severity of the peroneal tendons tears (according to Sobel classification) correlated with the hindfoot varus severity. III-IV grade of the peroneal tendons tears was observed more often in patients of II-III groups (p=0.0065). Hypertrophy and degenerative changes of the peroneal tubercle were revealed in 18 patients (fig.1). Oedematous changes of the peroneal tubercle were found mostly in the patients with the highest rates of calcaneus deviation (group III) (p=0.0016). In all the patients with symptomatic idiopathic cavovarus hindfoot, chronic lateral ligaments tears were found. Other pathologic conditions of ankle structures in these patients had no significant associations between them and hindfoot varus severity (p>0.05).

Conclusion:

Painful peroneal tubercle hypertrophy associated with peroneal tendinopathy is evident in patients with more pronounced cavovarus hindfoot deformity. The grade of peroneal tendons tears also increases with an increasing of hindfoot varus severity. Such pathologic conditions exacerbate chronic pain and the degree of ankle lateral instability and often require surgical correction.

Limitations:

n/a

Ethics committee approval

n/a

Funding:

No funding was received.

8
MyT3 5 - The role of diffusion-weighted MRI in the assessment of treatment response to chemotherapy in osteosarcoma

MyT3 5 - The role of diffusion-weighted MRI in the assessment of treatment response to chemotherapy in osteosarcoma

03:06L. Bokhary, Giza / EG

Purpose:

To investigate whether DWI is useful for monitoring the therapeutic response after chemotherapy in osteosarcoma by comparing the ADC values pre and post-treatment. And to determine if osteosarcomas change their water diffusion during preoperative chemotherapy in relation to the amount of tumour necrosis.

Methods and materials:

Inclusion criteria: osteosarcoma patients coming to the National Cancer Institue (NCI). Exclusion criteria: patients who have implanted electric and electronic devices and those who are intolerant to contrast administration. MRI techniques: conventional MRI, DWI and postgadolinium DTPA MR imaging initially and 3-6 months after chemotherapy administration. DWI analysis: qualitative analysis was done by studying the signal intensity of different lesions on both the DWIs (at the highest b value i.e. at 800sec/mm2) and the ADC map. Quantitative analysis: ADC calculation by using the electronic cursor on the ADC map in 3 different ROI of the lesion which was placed on the solid and preferably enhancing parts of the lesion excluding necrotic, fibrotic and haemorrhagic areas as well as adjacent fat, normal tissue and bone.

Results:

The study showed 17 patients with regressive response, 7 with a progressive response and only one case remained stationary. Follow-up MR after treatment showed increased intra-tumoural breaking down in (52%) of patients.

Conclusion:

DWI and ADC value in following-up the treatment of osteosarcoma revealed to increase the mean ADC value in regressive cases and vice versa in progressive cases. Following-up by MRI revealed increased in tumour breaking down in post-therapeutic conventional MRI.

Limitations:

None.

Ethics committee approval

Informed written consent was obtained from the patients after explanation of the procedure.

Funding:

No funding was received for this work.

9
MyT3 5 - Immediate morphological spine modification after positioning of removable interspinous spacer for unifocal lumbar canal stenosis

MyT3 5 - Immediate morphological spine modification after positioning of removable interspinous spacer for unifocal lumbar canal stenosis

02:58L. Pavan, Torino / IT

Purpose:

To evaluate the immediate morphological modifications on pre and post-procedural CT scan after percutaneous positioning of a removable interspinous spacer (ISS) for unifocal lumbar canal stenosis under fluoroscopic and CT guidance.

Methods and materials:

Patients treated in our centre between 12/2018 and 09/2019 with a percutaneous removable interspinous spacer (LobsterProject®, Techlamed®) for symptomatic unifocal lumbar stenosis were retrospectively selected. After general or epidural anaesthesia, under fluoroscopic and CT guidance, the ISS was percutaneously placed by two interventional radiologists in the central part of the interspinous ligament with lateral access. For each patient interspinous space, intradiscal space, intra-articular space and foraminal area (based on bone cortical on sagittal imaging) were measured on pre- and post-procedural low dose CT by two operators (OP1-OP2).

Results:

Nine patients were selected with a mean age of 80,1[68-92] years. Interspinous space significantly increased (-OP1:3.3 vs 8.8mm, p<0.01 -OP2:3.4 vs 9.7mm, p<0.01) as well as foraminal area (-OP1:132 vs 155mm2, p<0.01 -OP2:132 vs 163mm2, p<0.01), according to both operators. Intradiscal space (-OP1:6.2 vs 6.8mm, p=0.069 -OP2:6.3vs6.9mm, p=0.021) and intra-articular space (OP1:2.1 vs 2.9mm, p=0.076 -OP2:2.1 vs 3.3mm, p=0.011) increased too (statistically significant according to one operator). Mean operative time was 44 minutes. Technical positioning was satisfying in 8/9 cases.

Conclusion:

Interspinous spacer has immediate significant effects on lumbar morphology, significantly increasing interspinous space, foraminal area, intradiscal space and intra-articular space. The reduced invasiveness of the procedure and the possibility of percutaneous removal allows to avoid a major surgery, even if the ISS is not tolerated.

Limitations:

Limits of the study are the analysis on low-dose CT and lack of a long term clinical follow-up.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

10
MyT3 5 - Use of DISCOGEL® to treat cervical and lumbar discal bulging: results and consideration in our monocentric experience

MyT3 5 - Use of DISCOGEL® to treat cervical and lumbar discal bulging: results and consideration in our monocentric experience

03:04M. Spinetta, Santo Stefano Di Magra / IT

Purpose:

Intervertebral disc bulging is a radiologic sign due to the weakness of annulus fibrosus that causes compression on the inter-vertebral foramina with a symptoms characterized by back pain with or without limbs irradiation and functional limitation

Methods and materials:

We retrospectively evaluated our monocentric experience in 78 Patients affected by cervical and lumbar disc bulging treated with DISCOGEL®. Inclusion criteria were: at least 6 weeks failure of medical therapy and disc degeneration classified as Pfirmann grade 1-3. Patients selection was based on the evaluation of a spine MRI and clinical symptoms

Results:

We performed all the procedures in angiographic suite, with prone (lumbar treatment) or supine (cervical) position and in all of cases we injected 0,8 ml DISCOGEL® for every disc treated. No major adverse events have been reported. According to MacNab scale, in our experience, clinical success was achieved in the 75,7 % of cases (59/78 Patients). In the 24,3% of cases (19/78 Patients) the treatment was not efficient

Conclusion:

Our study demonstrates that DISCOGEL® is safe and efficient in the treatment of cervical and lumbar disc bulging, with a good clinical success and a low adverse events rate.

Limitations:

no randomization of our cohort of patients

Ethics committee approval

n/a

Funding:

No funding was received for this work

11
MyT3 5 - Pitfalls in imaging of TFCC

MyT3 5 - Pitfalls in imaging of TFCC

02:59O. Balazs, Timisoara / RO

Purpose:

The triangular fibrocartilage complex plays an important role in wrist biomechanics and is prone to traumatic and degenerative injury, making it a common source of ulnar-sided wrist pain. Diagnosis of injuries to the ligamentous structures of the wrist can be a challenge, particularly when there is involvement of the small, complex structures of the proximal wrist. A detailed understanding of the triangular fibrocartilage complex anatomy and injury patterns is critical in generating an accurate report to help guide treatment.

Methods and materials:

A retrospective review of MR wrists done in our institution over a two-year period was performed and illustrative cases were selected. A review of the normal anatomy of TFCC, imaging technique, normal MR appearance, Palmer classification, variant anatomy that mimic TFCC disease and spectrum of imaging findings in TFCC injury are discussed in the study.

Results:

Advances in magnetic resonance imaging have facilitated a better visualisation of the triangular fibrocartilage complex structures. However, there are a number of pitfalls that may cause difficulty in diagnosis of injuries to the triangular fibrocartilage complex, lunotriquetral ligament, and scapholunate ligament. The accuracy of diagnosis of injuries to the TFCC and wrist ligaments may decrease due to use of inappropriate MR imaging sequences or MR imaging artifacts, whereas variant anatomy of the proximal wrist structures may mimic disease of the TFCC and wrist ligaments.

Conclusion:

Knowledge of the detailed anatomy of the wrist, as well as variant patterns of structure morphology and signal intensity, can help differentiate actual disease from normal or variant appearances at the assessment with MR imaging.

Limitations:

None.

Ethics committee approval

N/A

Funding:

No funding was received for this work.

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