Primary tracheomalacia and gastroesophageal reflux in infants with cough

Cough is an uncommon sign in infants. Cough may result from the presence of abnormal secretions in the airway or abnormalities of the central airways that affect the infant's ability to clear normal secretions. Tracheomalacia (TM) and gastroesophageal reflux (GER) can both cause cough in infants. Four infants whose cough began in the newborn period were diagnosed with TM and GER. Symptoms of central airway obstruction (homophonous wheeze or tracheal cough) suggested the diagnoses. In three patients, the diagnosis was made by barium esophagraphy and airway fluoroscopy. The infants responded to conservative and medical therapy for GER and to nebulized bronchodilators. Tracheomalacia and GER cause cough in infants that begins in the newborn period. The diagnosis can often be made with studies available to the primary care provider, and the conditions are often responsive to medical management.

[Overview of the current status of measurable parameters of cartilage metabolism in various body fluids]

The human cartilage and bone is characterized by a remodeling during the life, well balanced by neosynthesis and degradation of matrix components. In different joint diseases, it becomes imbalanced and the destruction of the cartilage supersedes the repair. In tissue processes in disease and in normal turnover of the matrix, these molecules are fragmented and released into surrounding fluids, in the synovial fluid, and then in the blood and the urine, where they can be detected. The quantitative measurement in the synovial fluid is more specific than in the other body fluids. The research process in recent years has suggested that these molecular markers of cartilage and bone matrix metabolism can be used to determine diagnosis, the disease severity rather than its presence or absence, the prognosis, and the response to therapy. They should help to identify the disease mechanism in different joint diseases not only on the tissue but also on the molecular level. The specific cartilage matrix markers promise to become useful tools in the future in clinical use. The research in this area is still in the early stages, with most results dated from the end of the 1980s and the 1990s.

Auricular ossification

A patient with extensive bilateral auricular ossification presented with chondrodermatitis nodularis helicis on one side. The condition was otherwise asymptomatic. Ossification was detected on radiological and histological examination. Underlying medical conditions were not found. We believe this developed as a consequence of cold injury. Auricular ossification is an unusual cause of the so-called petrified external ear, in which the subcutaneous tissue is stony hard. It is more commonly caused by dystrophic calcification. Calcification and ossification are clinically identical and histological examination is required to definitively differentiate them.

MRI of patellar articular cartilage: evaluation of an optimized gradient echo sequence (3D-DESS)

Our purpose was to evaluate the diagnostic efficacy of a gradient-echo sequence optimized for cartilage imaging in patellar cartilage abnormalities and to compare it to a standard turbo-spin-echo sequence. Fifty-eight consecutive patients who underwent, within 3 months both MRI and arthroscopy or surgery, were included in the investigation. Two radiologists specializing in musculoskeletal imaging independently assessed axial three-dimensional double-echo steady state (3D-DESS) gradient-echo images and sagittal proton- and T2-weighted turbo-spin-echo images with regard to retropatellar cartilage abnormalities. Possible findings were: 0: normal, 1: cartilage softening, and 2: lesion of the articular surface. Inter- and intraobserver variability was assessed. For cartilage softening, the axial 3D-DESS sequence had a sensitivity of 73%, a specificity of 75%, and an accuracy of 70%. The corresponding results for the sagittal turbo-spin-echo sequence were 53%, 65%, and 62%. For surface lesions, the results for the 3D-DESS sequence were 43%, 92%, and 83% and for the turbo-spin-echo sequence were 60%, 92%, and 86%. Intra- and interobserver agreement was moderate (k = 0.59 and 0.45 [DESS], 0.6 and 0.46 [turbo -spin-echo]). We conclude that the 3D-DESS sequence is moderately accurate in detecting patellar cartilage abnormalities. Compared with the sagittal turbo-spin-echo sequence, the axial 3D-DESS sequence is superior in diagnosing cartilage softening but not surface lesions.

Fibro-osseous, osseous, and cartilaginous lesions of the orbit and paraorbital region. Correlative clinicopathologic and radiographic features, including the diagnostic role of CT and MR imaging

Fibro-osseous and cartilaginous lesions of the orbit and facial region share overlapping clinical, radiologic, and pathologic features that may lead to diagnostic confusion and possible misdiagnosis. The value of imaging studies in the histopathologic diagnosis of these lesions cannot be overemphasized. The histopathologic diagnosis of such lesions should not be rendered in the absence of radiographic correlation.

Cartilaginous disorders of the chest

Cartilaginous disorders of the thorax can arise in the parenchyma, airways, chest wall, and axial skeleton. At radiography, pulmonary hamartoma is characterized by "popcorn" calcification or fat density, either of which is diagnostic. Bronchiectasis is best demonstrated at high-resolution computed tomography (CT) and has a "tramline" or "signet ring" appearance. Tracheopathia osteochondroplastica appears at CT as multiple sessile submucosal nodules with or without calcification along the cartilaginous portion of the trachea. In relapsing polychondritis, the trachea and mainstem bronchi have diffuse or focal thickening with luminal narrowing at radiography. Costochondritis of the chest wall has become more prevalent with increased intravenous drug abuse and may be demonstrated at CT as soft-tissue swelling along with underlying cartilaginous fragmentation and bone destruction. Enchondromas are expansile and may display a calcified cartilaginous matrix at radiography. In osteochondroma, the thickness of the cartilaginous cap determines the likelihood of malignant degeneration. At radiography, chondroblastomas have a round contour, sharp margins, and cortical scalloping, whereas chondrosarcomas are large masses with indistinct margins, cortical breakthrough, and soft-tissue extension. By identifying either a process affecting a cartilage-containing structure or a cartilaginous matrix within a lesion, the chest radiologist may be able to narrow the list of differential diagnostic possibilities substantially.

Calcified vertical plate of the cricoid--a rare pitfall in the diagnosis of an oesophageal foreign body

We present a case of rare pitfall in the diagnosis of an oesophageal foreign body due to the calcified vertical plate of the cricoid to highlight the need to be aware of this entity to avoid unnecessary morbidity.

Evaluation of patellar cartilage surface lesions: comparison of CT arthrography and fat-suppressed FLASH 3D MR imaging

The aim of this study was to evaluate the sensitivity and specificity of fat-suppressed fast low-angle shot (FLASH) 3D MR imaging in the detection of patellar cartilage surface lesions in comparison with CT arthrography. Fifty patients, with or without symptoms of chondromalacia, were prospectively examined by CT arthrography and fat-suppressed 3D gradient-echo MR imaging. All MR examinations were evaluated by three observers, two of them reaching a consensus interpretation. The lesions were graded according to their morphology and their extent. The CT arthrography was considered as the reference examination. For both sets of observers, the final diagnosis of chondromalacia was obtained in 92.5 %. The specificity was 60 % on a patient-by-patient basis. Fissures were missed in 83 and 60 %, respectively, but were isolated findings only in 2.5 % of the cases. Considering ulcers involving more than 50 % of the cartilage thickness, 65 and 88 %, respectively, were recognized. Fat-suppressed FLASH 3D is an adequate pulse sequence for the detection of patellar cartilage ulcers. It can be applied on a routine clinical basis, but it does not show as many fissures as CT arthrography and is less precise for grading of lesions.

Correlation between radiographically diagnosed osteophytes and magnetic resonance detected cartilage defects in the patellofemoral joint

OBJECTIVE

To assess the correlation between radiographically diagnosed osteophytes in the axial and lateral view of the patellofemoral joint (PFJ) and (1) magnetic resonance (MR) detected cartilage defects in the same joint and (2) knee pain.

METHODS

Fifty-seven people with chronic knee pain, (aged 41-58 years, mean 50 years) were examined with axial and lateral radiograms when standing of the right and the left PFJ. The presence and grade of osteophytes was assessed. On the same day, a MR examination was performed of the signal knee with proton density and T2 weighted turbo spin-echo sequences in the sagittal and axial view on a 1.0 T imager. Cartilage defects in the PFJ were noted. The subjects were questioned for current knee pain for each knee.

RESULTS

Osteophytes at the PFJ had a specificity varying between 59 and 100% and a positive predictive value between 74 and 100% for MR detected cartilage defects. The corresponding values for osteophytes at the lateral aspect of the femoral trochlea were both 100%. In PFJ with narrowing (< 5 mm) osteophytes had a sensitivity and a positive predictive value of 90 and 95% respectively for MR detected cartilage defects, while in PFJ with non-narrowing (> or = 5 mm) the corresponding values were 75 and 65% and the specificity was 50%. A correlation (p < 0.05) between osteophytes at the inferior pole of the patella and knee pain was found.

CONCLUSIONS

Osteophytes at the PFJ are associated with MR detected cartilage defects in the same joint. The relation was strong for osteophytes at the lateral femoral trochlea and in the PFJ with narrowing (< 5 mm), but weak in the PFJ with non-narrowing (> or = 5 mm).

Correlation between radiographically diagnosed osteophytes and magnetic resonance detected cartilage defects in the tibiofemoral joint

OBJECTIVE

To assess the correlation between the presence of radiographically diagnosed osteophytes in the tibiofemoral joint (TFJ) and (1) magnetic resonance (MR) detected cartilage defects and meniscal lesions in the same joint and (2) knee pain.

METHODS

Fifty-nine people, 29 men and 30 women, with chronic knee pain (aged 41-58 years, mean 50 years) were examined with posteroanterior weightbearing radiograms in semiflexion of both TFJ. The presence and grade of marginal and central osteophytes were assessed. On the same day, an MR examination was performed of the signal knee with proton density and T2 weighted turbo spin-echo sequences on a 1.0 T imager. Cartilage defects and meniscal abnormalities in the TFJ were noted. The subjects were questioned for current knee pain for each knee.

RESULTS

Marginal osteophytes had a sensitivity of 77%, specificity of 83%, and positive predictive value of 87% for MR detected cartilage defects in the TFJ and a sensitivity of 71%, specificity of 68%, and positive predictive value of 71% for meniscal abnormalities. A correlation (p < 0.05) between osteophytes at the medial tibial condyle and knee pain was found.

CONCLUSIONS

With the presence of marginal osteophytes in the TFJ there is a high prevalence of MR detected cartilage defects in the same joint whether joint space narrowing (< 3 mm) is present or not.

[The initial (I and II) and advanced (III and IV) stages of juvenile patellar chondromalacia. Its diagnosis by magnetic resonance using a 1.5-T magnet with FLASH sequences]

PURPOSE

Juvenile patellar chondromalacia is a common orthopedic disorder which can mimic other conditions; early diagnosis is mandatory to prevent its evolution into osteoarthrosis. In the early stages of patellar chondromalacia (I and II), the lesions originate in the deep cartilage layer and the joint surface is not affected. Arthroscopy can demonstrate joint surface changes only and give indirect information about deeper lesions. We investigated the yield of 2D FLASH MRI with 30 degrees flip angle and a dedicated coil in the diagnosis of patellar chondromalacia, especially in its early stages.

MATERIAL AND METHODS

Eighteen patients (mean age: 21 years) with clinically suspected patellar chondromalacia were examined with MRI; 13 of them were also submitted to arthroscopy. A 1.5 T unit with a transmit-and-receive extremity coil was used. We acquired T1 SE sequences (TR/TE: 500-700/15/20) and 2D T2* FLASH sequence (TR/TE/FA: 500-800/18/30 degrees). The field of view was 160-180 mm and the matrix 192 x 256, with 2-3 NEX. The images were obtained on the axial plane. The lesions were classified in 4 stages according to Shahriaree classification.

RESULTS

Agreement between MR and arthroscopic findings was good in both early and advanced lesions in 12/13 cases. Early lesions appeared as hyperintense focal thickening of the hyaline cartilage (stage I) or as small cystic lesions within the cartilage and no articular surface involvement (stage II). The medial patellar facet was the most frequent site. Advanced lesions appeared as articular surface ulcerations, thinning and cartilage hypointensity (stage III); stage IV lesions presented as complete erosions of the hyaline cartilage and hypointense underlying bone.

CONCLUSIONS

2D FLASH MRI with 30 degrees flip angle can show the differences in water content in the cartilage and thus permit to detect early chondromalacia lesions in the deep cartilage.

[MRI and articular cartilage]

Although plain films are fundamental for routine imaging of degenerative chondral lesions, MRI is a promising tool of investigation for the articular cartilage. Its modalities are still imprecise and debated, but, because of its noninvasiveness, it is destined to be preferred over arthroCT. The small size of the cartilage requires thin slices of less than 3-mm thick. The various features of normal cartilage images must be well known. They depend on acquisition parameters, zonal structure of the cartilage and numerous artifacts (partial volume average, chemical shift, magnetic susceptibility, truncation, "magic angle"). Fast SE images provide a good compromise between contrast and the signal-to-noise ratio. T2-weighted images take advantage of an arthrographic effect in case of joint effusion. 3D GE images allow a more accurate evaluation with 1-mm thick slices. In all sequences, adding of a fat-suppression presaturation increases contrast between the cartilage and the surrounding structures. The diagnostic accuracies of the different sequences and of MR arthrography are discussed. Quantitative measurements of cartilage thickness and volume remain the topic of clinical research.

Tibial plateau erosions associated with lateral meniscal cysts

Although meniscal cysts are common, erosions of bone caused by these cysts are quite rare. We report MR imaging findings of two cases in which lateral meniscal cysts resulted in erosion of the lateral tibial plateau.

Sonographic appearances of meniscal cysts

PURPOSE

This study was conducted to define the sonographic appearances of cysts of the tibial menisci.

METHODS

Thirteen cases of meniscal cyst, proven by magnetic resonance imaging (MRI), were assessed using high-resolution sonography, and results of the 2 imaging modalities were correlated.

RESULTS

Seven meniscal cysts were lateral to the joint line, and 6 were located medially. MRI showed all 13 cysts to be associated with a tear of the adjoining meniscus. On sonograms, cyst size varied from 9 to 56 mm. Echotexture varied from uniformly hypoechoic or hypoechoic with echogenic septa to heterogeneously hyperechoic. Septated cysts were demonstrated by MRI and sonography.

CONCLUSIONS

Because of their diverse echo patterns, meniscal cysts may be easily mistaken for soft-tissue tumors, ganglions, or other lesions, which may result in surgery being inappropriately recommended. This is particularly true in the case of echogenic cysts. The cardinal sonographic characteristic of a meniscal cyst is its continuity with the meniscus, not its echotexture.

The pathological plica in the knee

Fourteen patients were evaluated who had an arthroscopic removal of the symptomatic mediopatellar plica of the knee in this retrospective study. The main complaint of the patients was the pain at the medial side of the knee. Before the operation only in 3 cases was the diagnosis the pathological plica. The arthroscopy was performed in a routine way. The plica was consider pathological, and removed, when it was thickened. There was grade I or II chondropathy in the knee on the medial femoral condyle and the patella respectively, caused by the plica. Good to excellent result were obtained in 93% of the knee with or without chondromalacia.

Recurrent aphthous stomatitis: clinical characteristics and associated systemic disorders

Recurrent aphthous stomatitis (RAS), commonly known as canker sores, has been reported as recurrent oral ulcers, recurrent aphthous ulcers, or simple or complex aphthosis. RAS is the most common inflammatory ulcerative condition of the oral mucosa in North American patients. One of its variants is the most painful condition of the oral mucosa. Recurrent aphthous stomatitis has been the subject of active investigation along multiple lines of research, including epidemiology, immunology, clinical correlations, and therapy. Clinical evaluation of the patient requires correct diagnosis of RAS and classification of the disease based on morphology (MiAU, MjAU, HU) and severity (simple versus complex). The natural history of individual lesions of RAS is important, because it is the bench mark against which treatment benefits are measured. The lesions of RAS are not caused by a single factor but occur in an environment that is permissive for development of lesions. These factors include trauma, smoking, stress, hormonal state, family history, food hypersensitivity and infectious or immunologic factors. The clinician should consider these elements of a multifactorial process leading to the development of lesions of RAS. To properly diagnose and treat a patient with lesions of RAS, the clinician must identify or exclude associated systemic disorders or "correctable causes." Behçet's disease and complex aphthosis variants, such as ulcus vulvae acutum, mouth and genital ulcers with inflamed cartilage (MAGIC) syndrome, fever, aphthosis, pharyngitis, and adenitis (FAPA) syndrome, and cyclic neutropenia, should be considered. The aphthous-like oral ulcerations of patients with human immunodeficiency virus (HIV) disease represent a challenging differential diagnosis. The association of lesions of RAS with hematinic deficiencies and gastrointestinal diseases provides an opportunity to identify a "correctable cause," which, with appropriate treatment, can result in a remission or substantial lessening of disease activity.

[Lesions of articular cartilage and their treatment]

Lesions of human articular cartilage most often are the result of a pathogenetically unclear disease process eventually leading to primary osteoarthrosis. The increasing incidence of traumatic injuries during sport activities, leading to lesions of cartilage and bone, is also worth noting. In addition, osteochondrosis dissecans and hereditary dysplasias of the skeletal system may lead to osseous and cartilaginous lesions. Adult articular cartilage has only very limited repair capacity in response to acute and chronic insults. Even now, diagnostic tools and methods of diagnosing cartilaginous lesions are still far from accurate. Lesions seen by conventional imaging technology chiefly represent late and irreversible damage of joint cartilage structures. The present review first summarizes current basic knowledge of joint anatomy and physiology, to enable the reader to understand better the unique nature of cartilaginous lesions and the difficulties and controversies involved in old and novel experimental methodologies in cartilage repair. It then critically evaluates developments in orthopedic therapy for repair of articular cartilage lesions.

Magnetization transfer and spin lock MR imaging of patellar cartilage degeneration at 0.1 T

PURPOSE

To investigate magnetization transfer (MT) parameters and rotating frame relaxation time T1 rho in patellar cartilage at different levels of degeneration.

MATERIAL AND METHODS

Thirty cadaveric patellae were examined at 0.1 T using the time-dependent saturation-transfer MT technique and the spin lock (SL) technique. In an SL experiment, nuclear spins are locked with a radiofrequency (RF) field, and the locked nuclear magnetization relaxes along the magnetic component of the locking RF field. The specimens were divided into three groups according to the level of cartilage degeneration. MT parameters and T1 rho were measured.

RESULTS

The MT effect was greater in degenerated cartilage than in normal cartilage. T1 rho was longer in advanced cartilage degeneration than in intermediate cartilage degeneration.

CONCLUSION

The results suggest that more studies are needed to fully establish the value of SL imaging in cartilage degeneration.

The utility of high-resolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist

We performed a prospective study in order to assess the utility of high-resolution magnetic resonance imaging in the detection and specific localization of tears of the triangular fibrocartilage complex. Seventy-seven patients who had pain in the wrist were studied with use of a dedicated surface coil and three-dimensional gradient-recalled techniques with a field of view of eight centimeters and a slice thickness of one millimeter. The patients had pain on the ulnar side of the wrist, ligamentous instability, occult ganglia, or a combination of these. Magnetic resonance images were assessed for radial or ulnar avulsion, or both; central defects; degenerative intrasubstance changes; and complex tears of the triangular fibrocartilage complex. Partial tears were differentiated from complete tears. The findings on the magnetic resonance images were then compared with the arthroscopic findings. Fifty-seven of the fifty-nine tears that were suspected on magnetic resonance images were confirmed with arthroscopy; the two suspected tears that were not confirmed had been interpreted as small partial tears on the magnetic resonance images. With use of arthroscopy as the standard, magnetic resonance imaging had a sensitivity of 100 per cent (fifty-seven of fifty-seven), a specificity of 90 per cent (eighteen of twenty), and an accuracy of 97 per cent (seventy-five of seventy-seven) for the detection of a tear (kappa = 0.93, p < 0.00001). Fifty-three of the fifty-seven tears were localized correctly with use of magnetic resonance imaging. With regard to the location of the tear, magnetic resonance imaging had a sensitivity of 100 per cent (fifty-three of fifty-three), a specificity of 75 per cent (eighteen of twenty-four), and an accuracy of 92 per cent (seventy-one of seventy-seven) (kappa = 0.9, p < 0.0001). We concluded that high-resolution magnetic resonance imaging permits accurate depiction and localization of tears of the triangular fibrocartilage complex. When the appropriate pulse sequence is used, magnetic resonance imaging is an accurate and effective method for the non-invasive evaluation of pain in the wrist.

Postero-anterior radiogram of the knee in weight-bearing and semiflexion. Comparison with MR imaging

PURPOSE

The purpose was four-fold: to assess the reproducibility of p.a. weight-bearing radiograms of the knee and the minimal joint-space (MJS) width measurements in these radiograms; to compare the MJS with MR-detected cartilage defects; to evaluate the location of these cartilage defects; and to estimate the relation between meniscal abnormalities and joint-space narrowing.

MATERIAL AND METHODS

Fifty-nine individuals, aged 41-58 years (mean 50), with chronic knee pain were examined by means of p.a. weight-bearing radiograms in semiflexion with fluoroscopic guidance of the knee joint. The MJS was measured with a standard ruler. On the same day MR imaging was performed with proton-density- and T2-weighted turbo spin-echo on a 1.0 T imager. Meniscal abnormalities and cartilage defects in the tibiofemoral joint (TFJ) were noted.

RESULTS AND CONCLUSION

The p.a. view of the knee and the MJS measurements were reproducible. MJS of 3 mm is a limit in diagnosing joint-space narrowing in knees with MR-detected cartilage defects. There was a high proportion (p < 0.001) of meniscal abnormality within the narrowed compartments in comparison with those that were not narrowed. A larger number of the cartilage defects (p < 0.05) was found in the medial femoral condyle than in any of the other condyles of the TFJ. The defects had a dorsal location (p < 0.001) as shown in the weight-bearing radiograms of the knee in semiflexion.

Adaptive filtering, modelling and classification of knee joint vibroarthrographic signals for non-invasive diagnosis of articular cartilage pathology

Interpretation of vibrations or sound signals emitted from the patellofemoral joint during movement of the knee, also known as vibroarthrography (VAG), could lead to a safe, objective, and non-invasive clinical tool for early detection, localisation, and quantification of articular cartilage disorders. In this study with a reasonably large database of VAG signals of 90 human knee joints (51 normal and 39 abnormal), a new technique for adaptive segmentation based on the recursive least squares lattice (RLSL) algorithm was developed to segment the non-stationary VAG signals into locally-stationary components; the stationary components were then modelled autoregressively, using the Burg-Lattice method. Logistic classification of the primary VAG signals into normal and abnormal signals (with no restriction on the type of cartilage pathology) using only the AR coefficients as discriminant features provided an accuracy of 68.9% with the leave-one-out method. When the abnormal signals were restricted to chondromalacia patella only, the classification accuracy rate increased to 84.5%. The effects of muscle contraction interference (MCI) on VAG signals were analysed using signals from 53 subjects (32 normal and 21 abnormal), and it was found that adaptive filtering of the MCI from the primary VAG signals did not improve the classification accuracy rate. The results indicate that VAG is a potential diagnostic tool for screening for chondromalacia patella.

Chondromalacia of the patella. Natural progression

A total of 42 cases of patellar pain in subjects aged an average of 17.2 years submitted to arthroscopy are analyzed. Femoropatellar balance, where indicated, led to resolution of disorders with full resumption of sports activity. In the remaining cases chondromalacia showed the features of an affection with a spontaneously favorable course, confirming the common orientation towards conservative treatment. Arthroscopy is effective for a correct classification of cartilaginous lesions, and it is a good instrument to use when attempting to achieve recovery of patellofemoral joint when disorders are caused by a lack of equilibrium.

Non-cartilaginous metaphyseal cysts in Legg-Calvé-Perthes disease: report of a case

Discrete metaphyseal radiolucent lesions, often termed "metaphyseal cysts", are a frequent finding in Legg-Calvé-Perthes disease. Recent literature emphasizes that such lesions represent ectopic physeal cartilage. This paper reports a case in which biopsy of the metaphyseal lesion indicated that no cartilage was present.