The costal cartilages in health and disease

The costal margin, although imaged in many routine radiologic examinations, has been ignored in the radiology literature. Calcification of the costal cartilages follows gender-related patterns and is generally not evident radiographically until after the age of 30 years. Diffuse enlargement of the costochondral junctions may alert the astute observer to the presence of systemic diseases such as acromegaly and rickets. Focal masses have a subtle appearance on plain radiographs and may be better imaged with computed tomography (CT) or magnetic resonance imaging. Chondrosarcoma of the costal margin typically appears as an expansile mass with coarse calcifications and an associated soft-tissue mass. Radiographic and CT features of costochondritis include chondral enlargement or destruction, low-attenuation cartilage at CT, associated soft-tissue swelling, and localized peripheral cartilage calcification. There appears to be an association between heavy premature costal cartilage calcification and certain systemic conditions, such as malignancy, autoimmune disorders, chronic renal failure, and thyroid disease, particularly Graves disease.

[Comparison of different MRT techniques in the diagnosis of degenerative cartilage diseases. In vitro study of 50 joint specimens of the knee at T1.5]

PURPOSE

An experimental study was performed on joint specimens of the knee to assess the advantages and disadvantages of 14 generally available sequences in cartilage imaging.

METHODS

Each of the 50 surgically exposed cadaveric joints of the knee was examined by the following sequences: T1, proton- and T2 weighted spin echo(SE) sequences, proton- and T2 weighted Turbo-SE, T1 weighted SE with fat suppression, MTC combined with T1-weighted SE and T2 weighted FLASH-2 D, STIR, FISP-3 D, FLASH-3 D (with fat suppression), and MR arthrography. We assessed the image quality by a scale, signal to noise-ratio of cartilage and joint fluid, and the accuracy in detection of cartilage lesions. Pathology and arthroscopy were reference methods to MRI, and demonstrated grade 1-4 lesions on 186 of 300 joint facettes.

RESULTS

Advanced stages of cartilage lesions (65 grade 3 and 4 lesions) were detected by standard SE sequences in 67-94%. Application of volume techniques (FISP-3 D, FLASH-3 D), high definition matrix (512 pixel), MTC with FLASH-2 D and MR-arthrography improved the sensitivity up to 82-100%. Superficial lesions (65 grade 2 lesions) were demonstrated in 3-38%, and on MR arthrography in 45%. Structural changes (56 Grade 1 lesions) were recorded on MR) in only 10%.

CONCLUSIONS

With regard to standard SE sequences, the detectability of cartilage lesions can be improved by techniques that use 512 matrices, selective cartilage imaging, and volume acquisition.

[What is your diagnosis? Costo-chondritis obscured by x-ray double-exposure]

The case of a 64 years old female patient with chest pain, dizziness and abnormal chest x-ray is presented. The different diagnostic possibilities are discussed. The final assessment in the case was a double radiographic exposure of the chest film confusing the clinical picture.

[Protracted course of polychondritis as the etiology of progressive nose deformity, subglottic tracheal stenosis and inner ear hearing loss]

BACKGROUND

Relapsing polychondritis is a rare recurring inflammatory disorder with variable clinical course. Its etiopathogenesis is unknown, but autoimmune mechanisms are likely to be involved.

PATIENT

We present a case report of a 42-year-old woman with polychondritis manifested in very slowly progressing destruction of the nasal cartilage, additional subglottic tracheal stenosis, and increasing cochlear dysfunction.

RESULT

We describe and document by a series of photographs the very protracted course of the disease in this patient from early youth until now. Clinical signs and differential diagnosis in polychondritis are discussed.

CONCLUSION

An early diagnosis in slowly progressing cases like this has to be established in order to permit adequate use of glucocorticoids and/or immunosuppressive drugs, to check the progress of the disease and prevent potentially lethal complications.

Chondropathia patellae

The articular surface of the patella and the contiguous articular surfaces of the femoral condyles are sometimes affected by disintegrational changes of the articular cartilage, which remain localized there for a longer period of time. In consideration of the pronounced functional impairment arising at marked changes of these articular surfaces, resection of the patellar surface, metallic resurfacing of the patella, periosteal resurfacing of the patella, or patellectomy have been described as treatment by various authors. Most of these modalities were followed by shortcomings of the results, as indicated in pertinent follow-up examinations and reports. Thus, a more physiological modality of treatment, organic resurfacing of the patella with synovial tissue, was applied in 7 patients and led to satisfactory results as ascertained by long-term follow-up examinations.

Chondromalacia of the knee: evaluation with a fat-suppression three-dimensional SPGR imaging after intravenous contrast injection

Twenty-one MRI studies with a fat-suppression three-dimensional spoiled gradient-recalled echo in a steady state (3D SPGR) pulse sequence after intravenous contrast injection were evaluated to assess the accuracy in depicting chondromalacia of the knee. On the basis of MR images, chondromalacia and its grade were determined in each of five articular cartilage regions (total, 105 regions) and then the results were compared to arthroscopic findings. The sensitivity, specificity, and accuracy of MRI were 70%, 99%, and 93%, respectively. MR images depicted 7 of 11 lesions of arthroscopic grade 1 or 2 chondromalacia, and seven of nine lesions of arthroscopic grade 3 or 4 chondromalacia. The cartilage abnormalities in all cases appeared as focal lesions with high signal intensity. Intravenous contrast-injection, fat-suppression 3D SPGR imaging showed high specificity in excluding cartilage abnormalities and may be considered as an alternative to intra-articular MR arthrography when chondromalacia is suspected.

Current status of imaging of articular cartilage

Various imaging methods have been applied to assessment of articular cartilage. These include standard radiography, arthrography, CT, CT arthrography, ultrasonography, and MR imaging. Radiography remains the initial musculoskeletal imaging method. However, it is insensitive to early stages of cartilage abnormalities. MR imaging has great potential in the assessment of articular cartilage, although high-quality scans are required because imaging signs of cartilage abnormalities may be subtle. The potential and limitations of various sequences and techniques are discussed, including MR arthrography. The role of the other imaging methods in assessment of articular cartilage appears to be limited.

Magnetic resonance imaging of labral cysts of the hip

OBJECTIVE

To present the magnetic resonance (MR) imaging findings in patients with labral cysts adjacent to the acetabulum and to examine their association with hip pathology.

DESIGN

MR images and conventional radiographs of seven patients with paralabral cysts were retrospectively reviewed by three musculoskeletal radiologists.

PATIENTS

The patients included three men and four women with hip pain, ranging in age from 29 to 82 years. Two patients had developmental dysplasia of the hip and six had a history of remote trauma/dislocation. Clinical history and follow-up were obtained in all patients. Surgery was performed on one patient.

RESULTS AND CONCLUSIONS

Paralabral cysts were located in the posterosuperior aspect of the hip joint in five patients and in the anterior aspect in two patients. A tear of the adjacent acetabular labrum was confirmed surgically in one patient, and in all patients the MR features suggested the presence of an abnormal labrum. Osteoarthritis was observed in three patients and there was associated subchondral cyst formation in the acetabulum adjacent to the cyst in three patients. The paralabral cyst of the hip is well visualized on MR imaging and is seen in patients with a predisposition to labral pathology.

Congenital cartilaginous rests of the neck

We describe a case of congenital cartilaginous rests of the neck arising on the suprasternal midline area of the neck in a Korean infant. The lesion was characterized by discrete nodules of mature elastic cartilage in the lower dermis or superficial subcutaneous soft tissue and multiple vellus hair follicles in the overlying skin.

[Knee problems--imaging techniques]

Standard radiographs still represent the standard imaging method in knee abnormalities. Major advantages include high spatial resolution, low cost, high availability and standardized imaging technique. Because there is an increasing pressure on the cost of health care, additional imaging should only be employed based on a working hypothesis. In most cases MR imaging is most suitable for further diagnosis. In internal knee derangements MR imaging has been shown to have a high negative predictive value, thus obviating unnecessary surgery. MR imaging also is the imaging method of choice in the detection and follow-up of arthritis, in the detection, staging and follow-up of malignant neoplasms, and in the detection of occult fractures. Ultrasonography is useful in the characterization of superficial soft-tissue abnormalities, but has not gained high acceptance in searching for internal derangements of the knee. Scintigraphy is competing with MR imaging in the early detection of bone abnormalities and for follow-up. However, it is less expensive and can be employed for the evaluation of multilocular processes. CT has a limited role in the evaluation of complex fractures mainly of the tibial plateau.

[Ulnodorsal impingement syndrome: meniscus lesions of the wrist]

In a consecutive series of 166 wrist arthroscopies, a lesion of the meniscus was found in 16 patients. All of them complained of ulnar wrist pain evoked by axial load in extension. 14 patients had previous wrist trauma. The preoperative physical examination showed marked ulnodorsal tenderness on palpation and the examiner could feel crepitation by passive motion in the radial-ulnar direction. The meniscus represents a part of the triangular fibrocartilage complex (TFCC). At this time it is not possible by magnetic resonance imaging (MRI) to differentiate between articular disc and meniscus lesion. In contrast the two structures are clearly identifiable by arthroscopy especially if there is a radial tear through the meniscus or even a complete avulsion from its insertion on the palmar aspect of the triquetrum. The avulsed part of the meniscus can prolapse into the ulnocarpal joint, causing an impingement phenomenon.

Diagnostic and quantitative arthroscopy: quantitative arthroscopy

Arthroscopy still remains the 'gold standard' for the assessment of articular cartilage and synovium because it provides direct and magnified evaluation of these anatomical structures. Thus, alongside the use of arthroscopy as a diagnostic or therapeutic procedure in knee disorders, a further function of knee arthroscopy, performed under local anaesthesia on an outpatient basis, has been proposed: the monitoring and follow-up of knee chondropathy and synovitis conducted for research purposes on patients suffering from knee osteoarthritis or chronic synovitis. This function is used in order (1) to evaluate the natural history of these diseases, (2) to assess 'de visu' the effect on chondral or synovial lesions of medical treatments or surgical interventions, and (3) to validate non-invasive imaging techniques such as plain radiographs or magnetic resonance imaging. The development of this arthroscopic outcome measurement of chondropathy and synovitis required the establishment and validation of systems for scoring the severity of chondral and synovial lesions. The author reviews both earlier and newer arthroscopic classifications and underlines the need for a quantitative description of cartilage and synovial abnormalities, either global and based on the investigator's overall assessment by using a visual analogue scale of severity, or, more analytically, taking into account the baseline parameters of the lesions, i.e. depth/intensity, extent and location.

Ankle arthroscopy under local and general anaesthesia for diagnostic evaluation and treatment

Improvements in techniques and instrumentation are extending the diagnostic and therapeutic indications for ankle arthroscopy. We aimed to study the diagnostic and therapeutic benefits and complication rate from 112 consecutive ankle arthroscopies performed between 1991 and 1994 under local and general anaesthesia. One-hundred and twelve outpatient ankle arthroscopies were performed in 72 male and 37 female patients, 16-64 years old. The patients were comparable in terms of gender and age in the arthroscopies done under local (n = 69) and the arthroscopies done under general anaesthesia (n = 43). The indications for surgery were pain in 75%, instability in 15%, limited function in 7% and swelling in 4%, and these criteria were similar in both groups. Antero-medial and anterolateral portals were used in all cases. No tourniquet was used and an external distractor was used in one case only. In 64 cases (57%) surgery was performed and included synovectomy, removal of loose bodies, shaving drilling of osteochondritic or other cartilage lesions, resection of impinging osteophytes, fibrosis and meniscoid lesions. In 95 ankles (85%) a definite diagnosis was established. Comparable diagnostic and therapeutic potentials were found between local and general anaesthesia. The complication rate was low. One patient who was operated on under general anaesthesia sustained a deep infection, and three suffered minor superficial nerve injuries. In conclusion, ankle arthroscopy may be performed under local or general anaesthesia with similar diagnostic value and with a low complication rate.

Idiopathic chondrolysis of the hip

A case of idiopathic chondrolysis of the hip is described in a 12 year old female who has the characteristics of arthroophthalmopathy (Stickler's syndrome). This common connective tissue dysplasia may go unrecognized and is possibly an aetiological factor in the development of this disease process. A review of the literature is presented.

Benign cartilage tumors

Benign cartilaginous tumors are some of the most common lesions affecting the skeleton of children. These include exostoses, enchondromas, periosteal chondromas, chondromyxoid fibroma, and chondroblastoma. The clinicopathologic features of these conditions and their treatment is discussed.

Emerging applications of magnetic resonance imaging in the evaluation of articular cartilage

MR imaging rapidly is emerging as a tool of unparalleled power for examining the articular cartilage and other important structures in diarthrodial joints. In addition to delineating the morphology of cartilage, MR imaging is capable of quantifying a variety of compositional and functional parameters relevant to arthritis. Moreover, because MR imaging is a nondestructive technique, multiple parameters can be analyzed in the same region of tissue and frequent serial examinations can be performed on even asymptomatic patients. This offers an unprecedented opportunity to study arthritis in ways not imaginable before and potentially to expand the envelope of MR imaging to include a population of patients for whom imaging has had relatively little to offer.

Juvenile chronic arthritis of the hip: value of contrast-enhanced MR imaging

OBJECTIVE

The purpose of this study was to assess the value of contrast-enhancement in MR diagnosis of hip joint disease in patients with juvenile chronic arthritis.

PATIENTS AND METHODS

Fourteen hips in seven children (four girls, three boys; mean age, 11 years; range, 7-17 years) with juvenile chronic arthritis for a mean duration of seven years (range, 3-15 years) were imaged on a 0.5T MR unit. One patient had an MR scan repeated after an 8-month interval. Axial and coronal T1-weighted spin-echo, and axial gradient-echo sequences were performed. T1 weighted axial sequences were repeated immediately after 0.1 mmol/kg of intravenous gadopentetate dimeglumine. Patients were assessed clinically for pain in the hip, range of motion at the hip joint, haemoglobin and erythrocyte sedimentation rate. Two radiologists, unaware of the patients symptoms, jointly assessed the unenhanced and contrast-enhanced scans for synovial hypertrophy (pannus), cartilage destruction and joint effusion.

RESULTS

Pannus was underestimated on 75% of unenhanced MR scans (95% binomial confidence intervals 54% to 93%). Enhancing pannus was seen in 14 of the 16 hip MR scans. Enhancing pannus was associated with articular cartilage destruction in all cases, and joint pain in 13 of 14 scans. Joint effusions were overestimated on unenhanced scans in all cases. Pannus could only reliably be distinguished from joint effusion after contrast enhancement. Both cases of loculated joint effusion were only seen after contrast enhancement.

CONCLUSION

Contrast-enhancement is recommended to aid MR detection of disease activity and extent in children with juvenile chronic arthritis of the hip.

Screening of vibroarthrographic signals via adaptive segmentation and linear prediation modeling

This paper proposes a noninvasive method to diagnose chondromalacia patella at its early stages by recording knee vibration signals (also known as vibroarthrographic or VAG signals) over the mid-patella during normal movement. An adaptive segmentation method was developed to segment the nonstationary VAG signals. The least squares modeling method was used to reduce the number of data samples to a few model parameters. Model parameters along with a few clinical parameters and a signal variability parameter were then used as discriminant features for screening VAG signals by applying logistic and discriminant algorithms. The system was trained using ten normal and eight abnormal signals. It correctly screened a separate test set of ten normal and eight abnormal signals except for one normal signal. The proposed method should find use as an alternative technique for diagnosis of knee joint pathology or as a test before arthroscopy or major knee surgery.

Chondromalacia of the trochlear notch in athletes who throw

Six athletes who throw and one shot-putter who underwent elbow arthroscopy were found to have an area of chondromalacia involving the posterolateral aspect of the olecranon. Preoperative symptoms were pain and tenderness to palpation over the lateral edge of the olecranon. On physical examination, range of motion was full or only slightly decreased (< 5 degrees) in five patients; coexistent loose bodies were also noted in two patients having a 20 degrees loss of extension. None of the patients exhibited ligamentous laxity to valgus stress testing of the elbow. During arthroscopy, the involved area was distinct from the bare area of the olecranon. This area was found as an isolated lesion in only one of seven patients; localized synovitis was noted in five patients, olecranon osteophytes in three, and loose bodies in two. A reciprocal lesion on the articular surface of the humerus was not identified in any patient. During arthroscopy, the lesion was debrided to a stable margin, and all associated pathologic conditions were addressed. Six of the seven athletes were able to return to their sport at premorbidity levels with this approach. This area of trochlear chondromalacia has not been previously described and, in our study, occurred in individuals whose elbows were subjected to repetitive valgus stress with lateral compression.