Novelties in slipped capital femoral epiphysis imaging: A narrative review

Rationale and objectives

Imaging plays a key role in Slipped Capital Femoral Epiphysis diagnosis and severity assessment. In the last two decades, signs and measurements emerged in literature showed potential to help in SCFE diagnosis and tailoring treatment. The purpose of this review is to collect and discuss new imaging signs, measurements, and techniques according to investigations published after 2000 to improve SCFE diagnosis.

Material and methods

The PubMed, Scopus, and Science Direct databases were used to search for relevant articles related to imaging in SCFE diagnosis from January 2000 to March 2023. Article selection and review was performed by two board-certified radiologists). Article quality assessment were conducted by authors using QUADAS-2 and SANRA evaluation tools.

Results

The research resulted in a total of 2577 articles. After duplicates removal and abstract analysis, 28 articles were finally selected for full-text analysis. Seventeen articles were focused on Radiographs, 6 on CT, 1 on both Radiographs and CT, 4 on MRI. No study focused on ultrasound was selected.

Conclusions

Use of modified Klein's line and S-sign may improve radiographs accuracy in daily routine. Lucency sign may help in early diagnosis on radiographs. Preoperative CT may be useful in planning a tailored treatment predicting SCFE severity and instability. MRI is the most accurate modality to diagnose SCFE at early stage. Nevertheless, it cannot be used to predict the risk of contralateral SCFE. Risk prediction can be assessed with radiographs, using a new rapid mOBS. Further investigation and validation of these sign is needed.

Imaging in osteogenesis imperfecta: Where we are and where we are going

Osteogenesis imperfecta (OI) is a rare phenotypically and genetically heterogeneous group of inherited skeletal dysplasias. The hallmark features of OI include bone fragility and susceptibility to fractures, bone deformity, and diminished growth, along with a plethora of associated secondary features (both skeletal and extraskeletal). The diagnosis of OI is currently made on clinical grounds and may be confirmed by genetic testing. However, imaging remains pivotal in the evaluation of this disease. The aim of this article is to review the current role played by the various radiologic techniques in the diagnosis and monitoring of OI in the postnatal setting as well as to discuss recent advances and future perspectives in OI imaging. Conventional Radiography and Dual-energy X-ray Absorptiometry (DXA) are currently the two most used imaging modalities in OI. The cardinal radiographic features of OI include generalized osteopenia/osteoporosis, bone deformities, and fractures. DXA is currently the most available technique to assess Bone Mineral Density (BMD), specifically areal BMD (aBMD). However, DXA has important limitations and cannot fully characterize bone fragility in OI based on aBMD. Novel DXA-derived parameters, such as Trabecular Bone Score (TBS), may provide further insight into skeletal changes induced by OI, but evidence is still limited. Techniques like Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) can be useful as problem-solvers or in specific settings, including the evaluation of cranio-cervical abnormalities. Recent evidence supports the use of High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT) as a promising tool to improve the characterization of bone fragility in OI. However, HR-pQCT remains a primarily research technique at present. Quantitative Computed Tomography (QCT) is an alternative to DXA for the determination of BMD at central sites, with distinct advantages but considerably higher radiation exposure. Quantitative Ultrasound (QUS) is a portable, inexpensive, and radiation-free modality that may complement DXA evaluation, providing information on bone quality. However, evidence of usefulness of QUS in OI is poor. Radiofrequency Echographic Multi Spectrometry (REMS) is an emerging non-ionizing imaging method that holds promise for the diagnosis of low BMD and for the prediction of fracture risk, but so far only one published study has investigated its role in OI. To conclude, several different radiologic techniques have proven to be effective in the diagnosis and monitoring of OI, each with their own specificities and peculiarities. Clinicians should be aware of the strategic role of the various modalities in the different phases of the patient care process. In this scenario, the development of international guidelines including recommendations on the role of imaging in the diagnosis and monitoring of OI, accompanied by continuous active research in the field, could significantly improve the standardization of patient care.

Association between markers of bone loss and urinary lithogenic risk factors in osteopenic postmenopausal women

In this study, we explored if urinary lithogenic risk parameters could have some application for monitoring bone health status. We recruited 20 women with postmenopausal osteopenia and a negative medical history for nephrolithiasis. Markers of lithogenic risk were evaluated on 24-h urine and fastingmorning urine. Serum levels of bone turnover markers (BTM) were measured in fasting-blood samples. We found that cross-linked telopeptide of type I collagen (CTX) was significantly correlated with 24-h calcium excretion. N-terminal propeptide of type I procollagen (PINP) correlated with 24-h excretion of potassium, calcium and citrate. CTX had considerably increased in patients with pH less than 5.5. Low citrate levels (less than 3.3 mmol/24 h) were associated with lower levels of CTX and PINP. Our findings suggest that a low-grade acidosis and some lithogenic risk factors are detectable in a proportion of patients with postmenopausal osteopenia. Further studies are necessary to confirm that this evaluation could be clinically relevant.

Trabecular bone score in healthy ageing

OBJECTIVE

The main aim of this work was to report on trabecular bone score (TBS) by dual-energy X-ray absorptiometry (DXA) of healthy Italian subjects to be used as a reference standard for future study in clinical and research settings. The secondary aim was to investigate the link between TBS and conventional parameters of bone and body composition by DXA.

METHODS

250 individuals of 5 age bands (spanning from 18 to 70 years of age, equally distributed for both age and sex) were prospectively recruited. A lumbar spine (LS) DXA scan (Lunar iDXA™; GE Healthcare, Madison, WI) was acquired for each subject and then analysed with the latest version of TBS iNsight v. 2.1 (Med-Imaps, Pessac, France) software. LS bone mineral density (LS BMD), Z-score, T-score and TBS values were collected. Pearson's test was used to investigate the correlations between TBS and LS BMD and the influence of age, body mass index (BMI) and body composition on these parameters.

RESULTS

A significant decrease of TBS and LS BMD was observed with ageing in both males (TBS mean values from 1.486 to 1.374; LS BMD mean values from 1.219 to 1.187) and females (TBS mean values from 1.464 to 1.306; LS BMD mean values from 1.154 to 1.116). No statistically significant difference was achieved among males and females of the same age group for both TBS and LS BMD, with the exception of the fifth age group. A significant correlation was found between LS BMD and TBS values in both sexes (r  = 0.555-0.655, p < 0.0001). BMI influenced LS BMD but not TBS. TBS values were inversely correlated with some fat mass parameters, in particular with visceral adipose tissue (in males: r = -0.332, p < 0.001; in females: r = -0.348, p < 0.0001). No significant correlation was found between TBS and total lean mass, opposite to LS BMD (in males: r = 0.418; p < 0.0001; in females: r = -0.235; p < 0.001).

CONCLUSION

This report is an attempt to start building a database for healthy Italian people providing age- and sex-specific reference curves for TBS. This could help clinicians to improve patient management in the detection of impaired bone mineral status and to monitor bone changes.

ADVANCES IN KNOWLEDGE

The study reports TBS values of a selectively enrolled Italian healthy population, ranging from younger to older ages and including males as a reference standard. Moreover, links between body composition and TBS are explored.

Liver in the analysis of body composition by dual-energy X-ray absorptiometry

OBJECTIVE

To investigate the predictive value for hepatic steatosis of a new software for the quantification of visceral fat by dual-energy X-ray absorptiometry (DXA) and to design new regions of interest (ROIs).

METHODS

Adult volunteers were prospectively screened for hepatic steatosis by ultrasonography to obtain a well-balanced population according to the presence/absence of the disease. 90 adult patients without steatosis and 90 with steatosis (mild, 53.3%; moderate, 37.7%; and severe, 10.0%) were recruited. On the same day, all subjects were submitted to blood testing and to anthropometric and whole-body DXA for body composition evaluation. A new software for android visceral fat assessment was employed, and six new "liver-suited" ROIs as well as two modified android ROIs were designed. Their association with steatosis grade was tested by correlation analysis.

RESULTS

Fat mass (FM) of the new ROIs showed the highest correlation coefficients with steatosis grade (ρ = 0.610-0.619; p < 0.001), which was also confirmed by multivariate analysis. On the whole population, the new ROIs maintained the highest predictive role for liver steatosis, with areas under the receiver operating characteristic curve up to 0.820 ± 0.032. Inter- and intra-operator agreement for the new ROIs was excellent (k = 0.915-1.000 and k = 0.927-1.000).

CONCLUSION

New ROIs could be designed, standardized and implemented in DXA whole-body scan to provide more specific and predictive values of hepatic lipid content.

ADVANCES IN KNOWLEDGE

This is the first study to investigate the predictive value for hepatic steatosis of visceral and regional FM assessed on the hepatic site by DXA in comparison with ultrasonography, anthropometry and surrogate markers derived by previously validated algorithms (fatty liver index).

MR-guided focused ultrasound (MRgFUS) ablation for the treatment of nonspinal osteoid osteoma: a prospective multicenter evaluation

BACKGROUND

Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel imaging-guided surgical technique that allows the performance of noninvasive and radiation-free ablation. Presently, computed tomography (CT)-guided radiofrequency ablation, a minimally invasive percutaneous technique, is the standard for treating symptomatic osteoid osteomas. The purpose of this study was to evaluate the use of MRgFUS ablation for the treatment of nonspinal osteoid osteomas in terms of technical success, complications, and clinical success through one year of follow-up.

METHODS

In this prospective multicenter study, thirty consecutive patients with a nonspinal osteoid osteoma were enrolled between May 2010 and April 2012 at three different university centers; twenty-nine of the patients were treated with use of MRgFUS. Lesions had been previously diagnosed on the basis of imaging, including dynamic contrast-enhanced MR. The mean number of sonications and energy deposition were determined. Technical success was evaluated through an assessment of complications immediately after treatment. Clinical success was determined on the basis of pain reduction as measured with a visual analog scale (VAS), recurrence, and long-term complications through twelve months.

RESULTS

Technical success of MRgFUS was observed for all twenty-nine patients. The mean number of sonications (and standard deviation) was 7 ± 3, and the mean delivered acoustic energy was 1180 ± 736 J. At the twelve-month follow-up, complete clinical success was observed in twenty-six (90%) of the twenty-nine patients (95% confidence interval [CI] = 84 to 95; mean VAS, 0 ± 0 points). Partial success was observed in three (10%) of the twenty-nine patients (95% CI = 5 to 16; mean VAS score, 5 ± 0 points); two of these patients subsequently underwent CT-guided radiofrequency ablation, and one underwent open surgery. Pain score values showed a significant reduction (p < 0.001) between baseline (mean VAS score, 8 ± 1 points) and post treatment (mean VAS score, 1 ± 2 points). No complications were observed.

CONCLUSIONS

MRgFUS may be an effective and safe alternative approach in the treatment of nonspinal osteoid osteoma. A complete clinical success rate of 90% was demonstrated without adverse events. MRgFUS is totally noninvasive and eliminates radiation exposure.

Localizer sequences of magnetic resonance imaging accurately identify osteoporotic vertebral fractures

The aim of the present study was to evaluate the performance of sagittal MR localizer (MR-loc), in terms of diagnostic accuracy and intra- and inter-observer agreement in the detection of vertebral fractures (VFs). Three-hundred MR examinations of the thoracic and/or lumbar spine were randomly collected. A semi-quantitative approach was used and morphometric analysis was performed when a VF was suspected. MR-loc images were evaluated blindly by three radiologists in two different sessions. A full diagnostic sagittal T1-weighted fast spin echo MR sequence was used as standard of reference (RS). Degenerative arthritis was also scored on RS. Only vertebral bodies which were assessable by both MR-loc and RS were considered for the analysis. Area under the receiver operating characteristic curve (AUROC), Cohen kappa statistic, and linear-by-linear association were used for statistical analysis. Kappa values were compared by means of the z distribution. A total of 2186 vertebrae were analysed in 300 MRI exams (147 males, 153 females, 59.4±16.4y.o.). Sixty-seven out of 2136 (3.1%) VFs were identified in 23/300 (7.7%) patients submitted to MRI. In the detection of VFs, sensitivity and specificity of MR-loc were both 100% (accuracy AUROC=1.000). Inter-observer agreement was excellent (k=0.938±0.013), while intra-observer agreement was perfect (k=1.000). The diagnostic performance was independent from degenerative arthritis, vertebral level, type and grade of VFs. MR-loc is a simple but accurate tool in the detection of VFs. It should be introduced for systematic evaluation in the detection of VFs in MR examinations performed in daily clinical practice.

Reliability and accuracy of scout CT in the detection of vertebral fractures

OBJECTIVE

The aim of the present study was to evaluate the reliability of scout CT (sCT) lateral radiograph, in terms of diagnostic accuracy and intra- and interobserver agreement in the detection of vertebral fractures (VFs).

METHODS

300 CT examinations of the thoracic and/or lumbar spine were collected and independently analysed by 3 musculoskeletal radiologists in 2 different sessions. A semi-quantitative approach was used for VF assessment on sCT, and morphometric analysis was performed when a VF was suspected. Results of multiplanar sagittal CT reconstructions interpreted by the most expert radiologist were considered as gold standard. Arthrosis was also scored. Only vertebral bodies assessable by both sCT and gold standard were considered for the analysis. Area under the receiver operating characteristic curve (AUROC), Cohen's kappa statistic and linear-by-linear association were used for statistical analysis.

RESULTS

1522 vertebrae were considered (130 males and 170 females; ages, 73.0±2.8 years). 73 of 1522 (4.8%) VFs were identified in 34/300 patients (11.3%). In the detection of VFs, the sensitivity and specificity of sCT were 98.7% and 99.7%, respectively. Accuracy (AUROC=0.992±0.008), as well as interobserver agreement (k=0.968±0.008), was excellent. Intra-observer agreement was perfect (k=1.000). Performance of this method was independent of arthrosis, vertebral level and type and grade of VFs.

CONCLUSION

sCT is a simple but very accurate method for the detection of VFs. It should be introduced as a spine evaluation tool for the detection of VFs in examinations that are performed for other diagnostic purposes.

ADVANCES IN KNOWLEDGE

sCT lateral radiograph is an accurate tool for the detection of VFs. This technique may be used with several advantages in clinical practice.

Relationships between total and regional adiposity and epicardial fat in obese women: how can dual-energy X-ray absorptiometry be associated with echocardiographic epicardial fat measurements?

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Obesity is an increasingly prevalent metabolic disorder and it is associated with a large number of comorbidities, including cardiovascular diseases. Adipose tissue is an active endocrine organ and its ectopic depots and distribution have different metabolic meanings on risks for health; as a matter of fact, epicardial fat seems to play a specific role in cardiovascular diseases. The use of dual-energy X-ray absorptiometry (DXA) to evaluate and follow-up patients affected by obesity is becoming a very important point in the management of the disease.

WHAT THIS STUDY ADDS

An investigation of the association between epicardial fat and regional adiposity by DXA in female obese patients. The total amount of central (trunk) fat mass is more strongly correlated than android visceral fat mass to epicardial thickness in obese women. In the interpretation of whole-body DXA data, physician should consider trunk fat mass for good and independent predictivity on epicardial fat depots. Our aim was to analyse in a population of obese women the relationship between the amount of epicardial fat as measured by transthoracic echocardiography (US) and the parameters of regional adiposity by dual-energy X-ray absorptiometry (DXA), with particular reference to a new software for visceral fat assessment and to a new 'heart-suited' regions of interests (ROIs). Sixty patients who satisfied technical inclusion criteria underwent whole-body DXA scan and US on the same day. Total and android fat mass (FM) and FM percentage (FM%) were considered as well as visceral fat (VAT) subcompartment in the android region; moreover, six new ROIs were designed on whole-body DXA images for the investigation of adiposity parameters at heart level. US provided epicardial fat thickness (EPI-thickness) and area (EPI-area), as measured following previously validated methods. Body mass index (BMI), gynoid and lower limbs (FM and FM%) were found not statistically correlated with EPI-thickness. The highest correlation was achieved by trunk FM (and FM%, with r = 0.544 and 0.480 respectively, P < 0.001), followed by ROI-1 FM (ROI-1 was drawn following thoroughly the cardiac profile), and android FM. Multivariate analysis including age, weight, BMI, trunk FM and the new ROIs (added one by one), retained in the final model trunk FM. Correlations of DXA with EPI-area were superimposable. In obese women, VAT or other new-designed ROIs are not better correlated than traditional ROIs (i.e. trunk) with epicardial fat amount.

Relationship between body composition, body mass index and bone mineral density in a large population of normal, osteopenic and osteoporotic women

PURPOSE

The knowledge of factors modulating the behaviour of bone mass is crucial for preventing and treating osteoporotic disease; among these factors, body weight (BW) has been shown to be of primary importance in postmenopausal women. Nevertheless, the relative effects of body composition indices are still being debated. Our aim was to analyze the relationship between body mass index (BMI), fat and lean mass and bone mineral density (BMD) in a large population of women. Moreover, this study represents a first important report on reference standard values for body composition in Italian women.

MATERIALS AND METHODS

Between 2005 and 2008, weight and height of 6,249 Italian women (aged 30-80 years) were measured and BMI was calculated; furthermore BMD, bone mineral content, fat and lean mass were measured by dual-energy X-ray absorptiometry. Individuals were divided into five groups by decades (group 1, 30.0-39.9; group 2, 40.0-49.9; group 3, 50.0-59.9; group 4, 60.0-69.9; group 5, 70.0-79.9). Differences among decades for all variables were calculated using a one-way analysis of variance (ANOVA) and Bonferroni test by the SPSS programme.

RESULTS

Mean BW was 66.8±12.1 kg, mean height 159.1±6.3 cm and mean BMI 26.4±4.7 kg/m(2). According to BW and BMI, there was an increase of obesity with age, especially in women older than 50 years (p<0.001). Lean mass increased until 50 years of age but significantly decreased after this age (p<0.001). The percentage of osteopenia and osteoporosis in the examined population was 43.0% and 16.7%, respectively.

CONCLUSIONS

Our data show that obesity significantly decreased the risk for osteoporosis but did not decrease the risk for osteopenia. It is strongly recommended that a strong policy regarding prevention of osteopenia and osteoporosis be commenced. An overall examination of our results suggests that both fat and lean body mass can influence bone mass and that their relative effect on bone could be modulated by their absolute amount and ratio to total BW.

Small (Radiol Med 2009;114:1239-66. [PMID: 19697104 DOI: 10.1007/s11547-009-0439-x]

PURPOSE

We prospectively compared gadoliniumenhanced magnetic resonance imaging (dynamic MRI), superparamagnetic iron oxide (SPIO) (ferucarbotran) MRI and multidetector-row computed tomography (MDCT) and the combination of dynamic MRI plus MDCT vs. dynamic MRI plus SPIO-MRI (double-contrast MRI: DC-MRI) for the detection of small (

MATERIALS AND METHODS

Sixty-three patients with liver cirrhosis and suspicious nodules detected during ultrasound (US) surveillance underwent DC-MRI in the same imaging session and MDCT within 15 days. The final diagnosis was established at pathology on the explanted liver (n=10), resection (n=6) and biopsy (n=38) specimens or at 2-years' follow-up (n=9).

RESULTS

One hundred and twenty-three nodules were detected: 87 were confirmed HCCs in 54 patients. The accuracy of SPIO-MRI and dynamic MRI were similar, both being superior to MDCT. Dynamic MRI demonstrated the highest sensitivity (83.9%; p<0.001). especially for lesions <1 cm (90.6%) - coupled with a lower specificity (36.1%) than SPIO-MRI, particularly in subcentimeter lesions (28.6%). SPIO-MRI demonstrated the highest sensitivity for nodules >1 cm and the highest specificity (83.3%) superior to dynamic MRI (p<0.0001). In the per-lesion analysis, SPIO-MRI demonstrated a positive predictive value higher than dynamic MRI (p=0.0059) and than both the combinations dynamic MRI/MDCT and DC-MRI (p=0.0021 and p=0.0087, respectively). DC-MRI showed the highest sensitivity (97.7%) and accuracy (78.9%), detecting hypovascular and atypical HCCs >1 cm. Furthermore its per-patient negative predictive value was the highest (100%), and significantly higher than all the other methods.

CONCLUSIONS

DC-MRI is the most sensitive and accurate method and can be confidently used as a single-step procedure for the detection of small HCCs, with the exception of lesions <1 cm.

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MESH Headings

• Adult
• Aged
• Aged, 80 and over
• Carcinoma, Hepatocellular/diagnosis
• Carcinoma, Hepatocellular/diagnostic imaging
• Contrast Media
• Dextrans
• Female
• Ferrosoferric Oxide
• Follow-Up Studies
• Gadolinium DTPA
• Humans
• Liver Cirrhosis/diagnosis
• Liver Cirrhosis/diagnostic imaging
• Liver Neoplasms/diagnosis
• Liver Neoplasms/diagnostic imaging
• Magnetic Resonance Imaging
• Magnetite Nanoparticles
• Male
• Middle Aged
• Predictive Value of Tests
• Prospective Studies
• Sensitivity and Specificity
• Tomography, X-Ray Computed

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Affiliation(s)

R Golfieri Radiologia Malpighi, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Università di Bologna, Via Albertoni 15, 40138, Bologna, Italy.
E Marini
A Bazzocchi
F Fusco
F Trevisani
C Sama
G Mazzella
S Cavuto
F Piscaglia
L Bolondi

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