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Tjörnstrand J, Neuman P, Svensson J, Lundin B, Dahlberg LE, Tiderius CJ. Osteoarthritis development related to cartilage quality-the prognostic value of dGEMRIC after anterior cruciate ligament injury. Osteoarthritis Cartilage 2019; 27:1647-1652. [PMID: 31279937 DOI: 10.1016/j.joca.2019.06.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/22/2019] [Accepted: 06/13/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Rupture of the anterior cruciate ligament (ACL) increases the risk of developing osteoarthritis (OA). Delayed Gadolinium enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) investigates cartilage integrity through T1-analysis after intravenous contrast injection. A high dGEMRIC index represents good cartilage quality. The main purpose of this prospective cohort study was to investigate the prognostic value of the dGEMRIC index regarding future knee OA. METHOD 31 patients with ACL injury (mean age 27 ± 6.7 (±SD) years, 19 males) were examined after 2 years with 1.5T dGEMRIC of femoral cartilage. Re-examination 14 years post-injury included weight-bearing knee radiographs, Lysholm and Knee Osteoarthritis Outcome Score (KOOS). RESULTS At the 14-year follow up radiographic OA (ROA) was present in 68% and OA symptoms (SOA) in 42% of the injured knees. The dGEMRIC index of the medial compartment was lower in knees that developed medial ROA, 325 ± 68 (ms±SD) vs 376 ± 47 (51 (7-94)) (difference of means (95% confidence interval (CI))), in patients that developed symptomatic OA (SOA), 327 ± 61 vs 399 ± 42 (52 (11-93)), and poor knee function 337 ± 54 vs 381 ± 52 (48 (7-89)) compared to those that did not develop ROA, SOA or poor function. The dGEMRIC index correlated negatively with the OARSI osteophyte score in medial (r = -0.44, P = 0.01) and lateral (r = -0.38, P = 0.03) compartments. CONCLUSION The associations between a low dGEMRIC index and future ROA, as well as SOA, are in agreement with previous studies and indicate that dGEMRIC has a prognostic value for future knee OA.
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Affiliation(s)
- J Tjörnstrand
- Orthopedics, Department of Clinical Sciences, Lund University, Skåne University Hospital, SE-221 85 Lund, Sweden.
| | - P Neuman
- Department of Orthopedics, Clinical Sciences, Lund University, Skåne University Hospital, SE-205 02 Malmö, Sweden
| | - J Svensson
- Department of Medical Imaging and Physiology, Skåne University Hospital, SE-221 85 Lund, Sweden; Medical Radiation Physics, Department of Translational Medicine, Lund University, SE-205 02 Malmö, Sweden
| | - B Lundin
- Department of Medical Imaging and Physiology, Skåne University Hospital, SE-221 85 Lund, Sweden
| | - L E Dahlberg
- Orthopedics, Department of Clinical Sciences, Lund University, Skåne University Hospital, SE-221 85 Lund, Sweden
| | - C J Tiderius
- Orthopedics, Department of Clinical Sciences, Lund University, Skåne University Hospital, SE-221 85 Lund, Sweden
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Lederer C, Hosalkar HS, Tiderius CJ, Westhoff B, Bittersohl B, Krauspe R. [Fixation techniques for slipped capital femoral epiphysis : Principles, surgical techniques, and complications]. Orthopade 2019; 48:659-667. [PMID: 31119306 DOI: 10.1007/s00132-019-03733-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The purpose of this review is to present the pros and cons as well as the surgical techniques of conventional implants used for fixation of slipped capital femoral epiphysis (SCFE). Worth mentioning are K‑wires, Hansson pins, transfixing screws, and gliding screws. We searched PubMed for "ECF" and "SCFE" in combination with "in situ fixation," "pin," "wire," "screw," and "nail." We considered Johansson nail, Knowles pin, and Nyström nail to be obsolete and of historical interest only. We noticed a trend from absolute stability towards some form of dynamic fixation over time, likely related to considerations of growth disturbance of the proximal femur and also the inherent potential for remodeling with time.
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Affiliation(s)
- C Lederer
- Orthopädische Klinik, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - H S Hosalkar
- Center for Hip Preservation and Children's Orthopedics, San Diego, USA
| | - C J Tiderius
- Department of Orthopedics, Skane University Hospital, Lund University, Lund, Schweden
| | - B Westhoff
- Orthopädische Klinik, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - B Bittersohl
- Orthopädische Klinik, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - R Krauspe
- Orthopädische Klinik, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
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Hangaard S, Gudbergsen H, Daugaard CL, Bliddal H, Nybing JD, Nieminen MT, Casula V, Tiderius CJ, Boesen M. Delayed gadolinium-enhanced MRI of menisci and cartilage (dGEMRIM/dGEMRIC) in obese patients with knee osteoarthritis: Cross-sectional study of 85 obese patients with intra-articular administered gadolinium contrast. J Magn Reson Imaging 2018; 48:1700-1706. [DOI: 10.1002/jmri.26190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/25/2018] [Indexed: 12/25/2022] Open
Affiliation(s)
- Stine Hangaard
- Parker Institute, Bispebjerg and Frederiksberg Hospital; Copenhagen Denmark
- Department of Radiology; Bispebjerg and Frederiksberg Hospital; Copenhagen Denmark
| | - Henrik Gudbergsen
- Parker Institute, Bispebjerg and Frederiksberg Hospital; Copenhagen Denmark
| | - Cecilie L. Daugaard
- Parker Institute, Bispebjerg and Frederiksberg Hospital; Copenhagen Denmark
- Department of Radiology; Bispebjerg and Frederiksberg Hospital; Copenhagen Denmark
| | - Henning Bliddal
- Parker Institute, Bispebjerg and Frederiksberg Hospital; Copenhagen Denmark
| | - Janus Damm Nybing
- Department of Radiology; Bispebjerg and Frederiksberg Hospital; Copenhagen Denmark
| | - Miika T. Nieminen
- Research Unit of Medical Imaging, Physics and Technology; University of Oulu; Oulu Finland
- Medical Research Center; University of Oulu and Oulu University Hospital; Oulu Finland
- Department of Diagnostic Radiology; Oulu University Hospital; Oulu Finland
| | - Victor Casula
- Research Unit of Medical Imaging, Physics and Technology; University of Oulu; Oulu Finland
- Medical Research Center; University of Oulu and Oulu University Hospital; Oulu Finland
| | - Carl-Johan Tiderius
- Department of orthopedics, Clinical Sciences Lund; Lund University, Skåne University Hospital; Lund Sweden
| | - Mikael Boesen
- Department of Radiology; Bispebjerg and Frederiksberg Hospital; Copenhagen Denmark
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Abstract
Background and purpose - Slipped capital femoral epiphysis (SCFE) results in a more or less pronounced deformity of the proximal femur, sometimes causing impingement and early osteoarthritis. We studied early osteoarthritis after SCFE and the association with deformity and self-reported hip function, pain, and quality of life. Patients and methods - 9 women and 16 men, mean age 32 (21-50) years, 19 with unilateral and 6 with bilateral SCFE, participated. All patients had primarily been operated by pin or screw with no attempt at reposition of the slip. Hips were examined by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), which quantifies and locates cartilage degeneration. Plain radiographs were used to measure deformity as determined by the alpha angle. Outcome was assessed by Oxford hip score, Hip Groin Outcome score and EQ-5D-Visual scale. Results - In the 19 unilateral SCFE, on the slip side dGEMRIC mean value was 533 ms (SD 112, range 357-649) versus mean 589 ms (SD 125, range 320-788) on the non-slip side, (p = 0.01). The dGEMRIC correlated negatively to the alpha angle, correlation coefficient (CC) = -0.60, (p = 0.002). Oxford hip score, pain, and EQ-5D-Visual scale correlated to dGEMRIC CC =0.43 (p = 0.03), CC =0.40 (p = 0.05), and CC =0.49 (p = 0.01) respectively. Interpretation - After SCFE, even relatively mild residual hip deformity can be associated with cartilage degeneration. A high alpha angle was associated with worse cartilage status. The Oxford hip score identified symptoms even though our patients had not previously sought medical care after the index operation. Quality of life showed strong inverse correlation with cartilage degeneration. Objective assessment of early cartilage degeneration may be useful for treatment decisions and follow-up.
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Affiliation(s)
| | | | - Ylva Aurell
- Department of Radiology, Mölndal Hospital, Sahlgrenska
| | | | - Johan Kärrholm
- Department of Orthopaedics, Mölndal Hospital, Sahlgrenska, Sweden
| | - Jacques Riad
- Department of Orthopaedics, Skaraborgs Hospital, Skövde,Correspondence:
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Sigurdsson U, Müller G, Siversson C, Lammentausta E, Svensson J, Tiderius CJ, Dahlberg LE. Delayed gadolinium-enhanced MRI of meniscus (dGEMRIM) and cartilage (dGEMRIC) in healthy knees and in knees with different stages of meniscus pathology. BMC Musculoskelet Disord 2016; 17:406. [PMID: 27682996 PMCID: PMC5041400 DOI: 10.1186/s12891-016-1244-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 09/08/2016] [Indexed: 12/23/2022] Open
Abstract
Background Lesions in the meniscus are risk factors for developing knee osteoarthritis (OA), not least because of the role of the meniscus in the pathological progression of OA. Delayed gadolinium enhanced MRI of cartilage (dGEMRIC) has extensively been used to identify pre-radiographic cartilage changes in OA. In contrast, its counterpart with regard to examination of the meniscus, gadolinium enhanced MRI of meniscus (dGEMRIM), has been less utilized. In this study we use 3D dGEMRIM in patients with meniscus lesions and compare them with previous results of healthy individuals. Methods Eighteen subjects with MRI-verified posteromedial meniscus lesions and 12 healthy subjects with non-injured and non-symptomatic knee joints, together 30 volunteers, were examined using 3D Look-Locker sequence after intravenous injection of Gd-DTPA2− (0.2 mmol/kg body weight). Relaxation time (T1) was measured in the posterior meniscus and femoral cartilage before and 60, 90, 120 and 180 min after injection. Relaxation rate (R1 = 1/T1) and change in relaxation rate (ΔR1) were calculated. For statistical analyses, Student’s t-test and Analysis of Variance (ANOVA) were used. Results The pre-contrast diagnostic MRI identified two sub-cohorts in the 18 patients with regard to meniscus injury: 1) 11 subjects with MRI verified pathological intrameniscal changes (grade 2) in the posteromedial meniscus only and no obvious cartilage changes. The lateral meniscus showed no pathology. 2) 7 subjects with MRI verified pathological rupture (grade 3) of the posteromedial meniscus and pathological changes in the lateral meniscus and/or medial and lateral joint cartilage. Comparisons of pathological and healthy posteromedial meniscus revealed opposite patterns in both T1Gd and ΔR1 values between pathological meniscus grade 2 and grade 3. The concentration of the contrast agent was lower than in healthy meniscus in grade 2 lesions (p = 0.046) but tended to increase in grade 3 lesions (p = 0.110). Maximum concentration of contrast agent was reached after 180 min in both cartilage and menisci (except for grade 3 menisci where the maximum concentration was reached after 90 min). Conclusion dGEMRIM and dGEMRIC may be feasible to combine in vivo, preferably with one examination before and one 2 h after contrast injection. Possible different dGEMRIM patterns at different stages of meniscus lesions must be taken into account when evaluating meniscus pathology.
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Affiliation(s)
- Ulf Sigurdsson
- Department of Orthopaedics, Lund University, Skåne University Hospital, SE-205 02, Malmö, Sweden.
| | - Gunilla Müller
- Institute of Radiology und Scintigraphy, Kantonsspital Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Carl Siversson
- Medical Radiation Physics, Department of Translational Medicine, Lund University, Skåne University Hospital, SE-205 02, Malmö, Sweden
| | - Eveliina Lammentausta
- Department of Diagnostic Radiology, Oulu University Hospital, PO Box 50, FI-90029 OYS, Oulu, Finland
| | - Jonas Svensson
- Medical Imaging and Physiology, Skåne University Hospital, SE-221 85, Lund, Sweden
| | - Carl-Johan Tiderius
- Department of Orthopaedics, Clinical Sciences Lund, Lund University, Skåne University Hospital, SE-221 85, Lund, Sweden
| | - Leif E Dahlberg
- Department of Orthopaedics, Clinical Sciences Lund, Lund University, Skåne University Hospital, SE-221 85, Lund, Sweden
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Hawezi ZK, Lammentausta E, Svensson J, Roos EM, Dahlberg LE, Tiderius CJ. Regional dGEMRIC analysis in patients at risk of osteoarthritis provides additional information about activity related changes in cartilage structure. Acta Radiol 2016; 57:468-74. [PMID: 26113741 DOI: 10.1177/0284185115591237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/18/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND Previously, a positive effect of exercise on cartilage structure was indicated with delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC). However, in that study only one full-thickness region of interest (ROI) in the medial femoral condyle was analyzed. PURPOSE To improve the knowledge about exercise effects on cartilage structure by re-analyzing previous images with regional dGEMRIC analysis. MATERIAL AND METHODS Thirty patients (age range, 38-50 years) with a previous medial meniscus resection were divided into three groups according to self-reported change in physical activity (PA) level in a 4-month exercise intervention study: Group I (n = 11), increased PA level; Group II (n = 13), no change in PA level; and Group III (n = 6), reduced PA level. dGEMRIC index was analyzed at inclusion and after 4 months. Anterior (less load) and posterior (more load) ROIs of medial and lateral femoral condyles were analyzed, as well as superficial and deep cartilage regions. RESULTS Group I increased the dGEMRIC index in the posterior cartilage (P = 0.004). The increase was larger in the lateral (P = 0.005) than the medial compartment in both superficial and deep cartilage regions. The dGEMRIC index did not change in Group II. In Group III, the dGEMRIC index decreased in the medial posterior cartilage (P = 0.03). CONCLUSION In patients with a previous medial meniscectomy, the beneficial effect of exercise varies between different locations within the joint, the largest improvement being observed in lateral posterior cartilage, i.e. the load-bearing cartilage in the compartment without a meniscus lesion. The effects of exercise do not seem to vary with cartilage depth.
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Affiliation(s)
- ZK Hawezi
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - E Lammentausta
- Department of Diagnostic Radiology, Oulu University Hospital, Finland
| | - J Svensson
- Department of Radiation Physics, Skåne University Hospital Malmö, Lund University, Sweden
| | - EM Roos
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - LE Dahlberg
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - CJ Tiderius
- Department of Orthopedics, Skåne University Hospital, Lund University, Sweden
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7
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Owman H, Ericsson YB, Englund M, Tiderius CJ, Tjörnstrand J, Roos EM, Dahlberg LE. Association between delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) and joint space narrowing and osteophytes: a cohort study in patients with partial meniscectomy with 11 years of follow-up. Osteoarthritis Cartilage 2014; 22:1537-41. [PMID: 24583348 DOI: 10.1016/j.joca.2014.02.929] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/22/2014] [Accepted: 02/19/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the association between the relaxation time (T1Gd) of delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and grade of tibiofemoral joint space narrowing (JSN) and osteophytosis 11 years later, in a cohort of meniscectomized patients. DESIGN Patients (n = 45) aged 35-50 who had undergone an arthroscopic partial medial meniscectomy 1-6 years earlier, due to degenerative meniscal tear, were examined using dGEMRIC. These patients had no cartilage changes defined as deep clefts or visible bone at the time of arthroscopy. Eleven years later (12-16 years after surgery) 34 of these subjects (76%) were evaluated by weight-bearing knee radiography, and tibiofemoral joint changes were graded according to the Osteoarthritis Research Society International Atlas. RESULTS Lower T1Gd in the medial compartment was associated with higher grade of medial JSN (grade 0, 351 ms; grade 1, 386 ms; grade 2, 342 ms; grade 3, 259 ms [P for trend < 0.001]) and more osteophytosis (score 0, 371 ms; score 1, 389 ms; score 2, 354 ms; score 3, 289 ms; score 4, 265 ms; score 5, 275 ms [P for trend = 0.001]). Lower T1Gd in the lateral compartment was associated with higher grade of lateral JSN (grade 0, 436 ms; grade 1, 346 ms [P for trend = 0.026]). CONCLUSION The current study suggests that lower T1Gd measured with dGEMRIC of medial and lateral femoral cartilage is associated with higher grade of JSN 11 years later, and medially, also with more osteophytosis.
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Affiliation(s)
- H Owman
- Department of Orthopaedics, Clinical Sciences, Lund University, Malmö, Sweden.
| | - Y B Ericsson
- Department of Orthopaedics, Clinical Sciences, Lund University, Malmö, Sweden
| | - M Englund
- Department of Orthopaedics, Clinical Sciences, Lund University, Lund, Sweden; Clinical Epidemiology Research & Training Unit, Boston University School of Medicine, Boston, MA, USA
| | - C J Tiderius
- Department of Orthopaedics, Clinical Sciences, Lund University, Malmö, Sweden
| | - J Tjörnstrand
- Department of Orthopaedics, Clinical Sciences, Lund University, Malmö, Sweden
| | - E M Roos
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - L E Dahlberg
- Department of Orthopaedics, Clinical Sciences, Lund University, Malmö, Sweden; Department of Orthopaedics, Clinical Sciences, Lund University, Lund, Sweden
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Kijowski R, Roemer F, Englund M, Tiderius CJ, Swärd P, Frobell RB. Imaging following acute knee trauma. Osteoarthritis Cartilage 2014; 22:1429-43. [PMID: 25278054 DOI: 10.1016/j.joca.2014.06.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/21/2014] [Accepted: 06/03/2014] [Indexed: 02/02/2023]
Abstract
Joint injury has been recognized as a potent risk factor for the onset of osteoarthritis. The vast majority of studies using imaging technology for longitudinal assessment of patients following joint injury have focused on the injured knee joint, specifically in patients with anterior cruciate ligament injury and meniscus tears where a high risk for rapid onset of post-traumatic osteoarthritis is well known. Although there are many imaging modalities under constant development, magnetic resonance (MR) imaging is the most important instrument for longitudinal monitoring after joint injury. MR imaging is sensitive for detecting early cartilage degeneration and can evaluate other joint structures including the menisci, bone marrow, tendons, and ligaments which can be sources of pain following acute injury. In this review, focusing on imaging following acute knee trauma, several studies were identified with promising short-term results of osseous and soft tissue changes after joint injury. However, studies connecting these promising short-term results to the development of osteoarthritis were limited which is likely due to the long follow-up periods needed to document the radiographic and clinical onset of the disease. Thus, it is recommended that additional high quality longitudinal studies with extended follow-up periods be performed to further investigate the long-term consequences of the early osseous and soft tissue changes identified on MR imaging after acute knee trauma.
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Affiliation(s)
- R Kijowski
- Department of Radiology, University of Wisconsin, Madison, WI, USA.
| | - F Roemer
- Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany; Department of Radiology, Boston University, Boston, MA, USA
| | - M Englund
- Department of Orthopedics, Clinical Sciences Lund, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University, Boston, MA, USA
| | - C J Tiderius
- Department of Orthopedics, Clinical Sciences Lund, Lund, Sweden
| | - P Swärd
- Department of Orthopedics, Clinical Sciences Lund, Lund, Sweden
| | - R B Frobell
- Department of Orthopedics, Clinical Sciences Lund, Lund, Sweden
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9
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Sigurdsson U, Siversson C, Lammentausta E, Svensson J, Tiderius CJ, Dahlberg LE. In vivo transport of Gd-DTPA2- into human meniscus and cartilage assessed with delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). BMC Musculoskelet Disord 2014; 15:226. [PMID: 25005036 PMCID: PMC4125346 DOI: 10.1186/1471-2474-15-226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 07/01/2014] [Indexed: 11/11/2022] Open
Abstract
Background Impaired stability is a risk factor in knee osteoarthritis (OA), where the whole joint and not only the joint cartilage is affected. The meniscus provides joint stability and is involved in the early pathological progress of OA. Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) has been used to identify pre-radiographic changes in the cartilage in OA, but has been used less commonly to examine the meniscus, and then using only a double dose of the contrast agent. The purpose of this study was to enable improved early OA diagnosis by investigate the temporal contrast agent distribution in the meniscus and femoral cartilage simultaneously, in healthy volunteers, using 3D dGEMRIC at two different doses of the contrast agent Gd-DTPA2-. Methods The right knee in 12 asymptomatic volunteers was examined using a 3D Look-Locker sequence on two occasions after an intravenous injection of a double or triple dose of Gd-DTPA2- (0.2 or 0.3 mmol/kg body weight). The relaxation time (T1) and relaxation rate (R1 = 1/T1) were measured in the meniscus and femoral cartilage before, and 60, 90, 120 and 180 minutes after injection, and the change in relaxation rate (ΔR1) was calculated. Paired t-test and Analysis of Variance (ANOVA) were used for statistical evaluation. Results The triple dose yielded higher concentrations of Gd-DTPA2- in the meniscus and cartilage than the double dose, but provided no additional information. The observed patterns of ΔR1 were similar for double and triple doses of the contrast agent. ΔR1 was higher in the meniscus than in femoral cartilage in the corresponding compartments at all time points after injection. ΔR1 increased until 90-180 minutes in both the cartilage and the meniscus (p < 0.05), and was lower in the medial than in the lateral meniscus at all time points (p < 0.05). A faster increase in ΔR1 was observed in the vascularized peripheral region of the posterior medial meniscus, than in the avascular central part of the posterior medial meniscus during the first 60 minutes (p < 0.05). Conclusion It is feasible to examine undamaged meniscus and cartilage simultaneously using dGEMRIC, preferably 90 minutes after the injection of a double dose of Gd-DTPA2- (0.2 mmol/kg body weight).
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Affiliation(s)
- Ulf Sigurdsson
- Department of Orthopaedics, Lund University, Skåne University Hospital, SE-205 02 Malmö, Sweden.
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Owman H, Tiderius CJ, Ericsson YB, Dahlberg LE. Long-term effect of removal of knee joint loading on cartilage quality evaluated by delayed gadolinium-enhanced magnetic resonance imaging of cartilage. Osteoarthritis Cartilage 2014; 22:928-32. [PMID: 24795270 DOI: 10.1016/j.joca.2014.04.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 03/31/2014] [Accepted: 04/22/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Ankle fracture patients were used as a model to study the long-term effect of the removal of joint loading on knee cartilage quality in human subjects. DESIGN The knees of 10 patients with ipsilateral ankle fractures were investigated using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) at the time of ankle injury. After 6 weeks' prescribed unloading of the affected leg, but no restrictions regarding knee movement, the cast was removed from the ankle and the patient underwent a second dGEMRIC examination. Physiotherapy was then initiated. A third dGEMRIC examination was performed 4 months after remobilization, and a final examination 1 year after the injury. RESULTS Baseline T1Gd values for the 10 patients were within a narrow range. No significant change in mean T1Gd was observed after 6 weeks' prescribed unloading, but the T1Gd range had increased significantly. Four months after remobilization, the mean T1Gd was significantly lower than in the previous examinations, and the range remained significantly broader than at baseline. At the 1-year follow-up, the mean T1Gd was almost identical to the value after remobilization, and the T1Gd range still showed a significant increase compared to the baseline investigation. CONCLUSIONS Removal of knee cartilage loading for 6 weeks resulted in a measurable effect on the cartilage matrix, as evidenced by a broader T1Gd range. A decrease in mean T1Gd was observed 4 months after remobilization. These differences persisted a year after injury compared to baseline.
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Affiliation(s)
- H Owman
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden.
| | - C J Tiderius
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden
| | - Y B Ericsson
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden
| | - L E Dahlberg
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden
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11
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Neuman P, Owman H, Müller G, Englund M, Tiderius CJ, Dahlberg LE. Knee cartilage assessment with MRI (dGEMRIC) and subjective knee function in ACL injured copers: a cohort study with a 20 year follow-up. Osteoarthritis Cartilage 2014; 22:84-90. [PMID: 24185106 DOI: 10.1016/j.joca.2013.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 08/31/2013] [Accepted: 10/22/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess knee cartilage quality and subjective knee function, 20 years after injury in anterior cruciate ligament (ACL) injured copers. METHOD We examined 32 knees using delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC), 20 years after a complete ACL tear. Only subjects who had coped with the ACL injury without ACL reconstruction (ACLR), and who presented without radiographic signs of osteoarthritis (OA) at an earlier 16-year follow-up, were included in this study. The quality of the central weight-bearing parts of the medial and lateral femoral cartilage was estimated with dGEMRIC (T1Gd). These results were compared with corresponding results in 24 healthy individuals, and with the subjects' self-reported subjective knee function using the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. RESULTS The values of T1Gd in the medial and lateral femoral cartilage of the study group (mean (95% CI)), were 404 (385-423) and 427 (399-455) ms, not statistically different from those of the healthy reference group (P = 0.065 and 0.31). The subjective knee function 20 years after the injury, according to the five domains of the KOOS score, was good, with a mean score of 90 ± 11. Values of T1Gd for the medial femoral cartilage were correlated with the KOOS subgroup QOL (P = 0.021, Pearson correlation). CONCLUSIONS Subjects who have managed to cope with their ACL injury for 20 years with sustained good subjective knee function also seem to have knee cartilage of good quality, with T1Gd values not very different from a healthy reference group.
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Affiliation(s)
- P Neuman
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden.
| | - H Owman
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden
| | - G Müller
- Department of Radiology, Clinical Sciences, Malmö, Lund University, Sweden
| | - M Englund
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden; Clinical Epidemiology Research & Training Unit, Boston University School of Medicine, Boston, MA, USA
| | - C J Tiderius
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden
| | - L E Dahlberg
- Department of Orthopaedics, Clinical Sciences, Malmö, Lund University, Sweden
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Abstract
BACKGROUND AND PURPOSE As much as one-third of all total hip arthroplasties in patients younger than 60 years may be a consequence of developmental dysplasia of the hip (DDH). Screening and early treatment of neonatal instability of the hip (NIH) reduces the incidence of DDH. We examined the radiographic outcome at 1 year in children undergoing early treatment for NIH. SUBJECTS AND METHODS All children born in Malmö undergo neonatal screening for NIH, and any child with suspicion of instability is referred to our clinic. We reviewed the 1-year radiographs for infants who were referred from April 2002 through December 2007. Measurements of the acetabular index at 1 year were compared between neonatally dislocated, unstable, and stable hips. RESULTS The incidence of NIH was 7 per 1,000 live births. The referral rate was 15 per 1,000. 82% of those treated were girls. The mean acetabular index was higher in dislocated hips (25.3, 95% CI: 24.6-26.0) than in neonatally stable hips (22.7, 95% CI: 22.3-23.2). Girls had a higher mean acetabular index than boys and left hips had a higher mean acetabular index than right hips, which is in accordance with previous findings. INTERPRETATION Even in children who are diagnosed and treated perinatally, radiographic differences in acetabular shape remain at 1 year. To determine whether this is of clinical importance, longer follow-up will be required.
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Affiliation(s)
- Daniel Wenger
- Department of Orthopaedics, Malmö, Skåne University Hospital, Sweden
| | - Henrik Düppe
- Department of Orthopaedics, Malmö, Skåne University Hospital, Sweden
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13
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van Tiel J, Bron EE, Tiderius CJ, Bos PK, Reijman M, Klein S, Verhaar JAN, Krestin GP, Weinans H, Kotek G, Oei EHG. Reproducibility of 3D delayed gadolinium enhanced MRI of cartilage (dGEMRIC) of the knee at 3.0 T in patients with early stage osteoarthritis. Eur Radiol 2012; 23:496-504. [PMID: 22886535 DOI: 10.1007/s00330-012-2616-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/19/2012] [Accepted: 07/12/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the reproducibility of 3D delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) at 3 T in early stage knee osteoarthritis (OA) patients. METHODS In 20 patients, 3D dGEMRIC at 3 T was acquired twice within 7 days. To correct for patient motion during acquisition, all images were rigidly registered in 3D. Eight anatomical cartilage ROIs were analysed on both images of each patient. Capability of dGEMRIC to yield T1 maps that reproducibly distinguish spatial differences in cartilage quality was assessed in two ROIs within a single slice in each patient. Reproducibility was assessed using ICCs and Bland-Altman plots. RESULTS ICCs ranged from 0.87 to 0.95, indicating good reproducibility. T1 maps revealed reproducible spatial differences in cartilage quality (ICC 0.79). Based on the Bland-Altman plots, we defined a threshold of 95 ms to determine if a change in dGEMRIC outcome in longitudinal research was statistically significant. CONCLUSIONS 3D knee dGEMRIC at 3 T combined with 3D image registration is a highly reproducible measure of cartilage quality in early stage OA. Therefore, dGEMRIC may be a valuable tool in the non-invasive evaluation of cartilage quality changes in longitudinal research in patients with early stage OA and focal cartilage defects.
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Affiliation(s)
- J van Tiel
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.
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14
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Siversson C, Chan J, Tiderius CJ, Mamisch TC, Jellus V, Svensson J, Kim YJ. Effects of B1 inhomogeneity correction for three-dimensional variable flip angle T1 measurements in hip dGEMRIC at 3 T and 1.5 T. Magn Reson Med 2011; 67:1776-81. [DOI: 10.1002/mrm.23150] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 07/10/2011] [Accepted: 07/21/2011] [Indexed: 11/09/2022]
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15
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Neuman P, Tjörnstrand J, Svensson J, Ragnarsson C, Roos H, Englund M, Tiderius CJ, Dahlberg LE. Longitudinal assessment of femoral knee cartilage quality using contrast enhanced MRI (dGEMRIC) in patients with anterior cruciate ligament injury--comparison with asymptomatic volunteers. Osteoarthritis Cartilage 2011; 19:977-83. [PMID: 21621622 DOI: 10.1016/j.joca.2011.05.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Revised: 04/08/2011] [Accepted: 05/05/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE In this observational longitudinal study we estimate knee joint cartilage glycosaminoglycan (GAG) content, in patients with an acute anterior cruciate ligament (ACL) injury, with or without a concomitant meniscus injury. METHODS 29 knees (19 men/10 women) were prospectively examined by repeat delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), approximately 3 weeks and 2.3±1.3 (range 4.5) years after the injury. We estimated the GAG content (T1Gd) in the central weight-bearing parts of the medial and lateral femoral cartilage and compared results with a reference cohort (n=24) with normal knees and no history of injury examined by dGEMRIC at one occasion previously. RESULTS The healthy reference group had longer T1Gd values compared with the ACL-injured patients at follow-up both medially: 428±38 vs 363±61ms (P<0.0001) and laterally: 445±41 vs 396±48ms (P=0.0002). At follow-up T1Gd was lower in meniscectomized patients compared to those without a meniscectomy, both medially (-84ms, P=0.002) and laterally (-38ms, P=0.05). In the injured group, the medial femoral cartilage showed similar T1Gd at the two dGEMRIC investigations: 357±50 vs 363±61ms (P=0.57), whereas the lateral femoral cartilage T1Gd increased: 374±48 vs 396±48ms (P=0.04). CONCLUSIONS The general decrease in cartilage T1Gd in ACL-injured patients compared with references provide evidence for structural matrix GAG changes that seem more pronounced if a concomitant meniscal injury is present. The fact that post-traumatic OA commonly develops in ACL-injured patients, in particularly those with meniscectomy, suggests that shorter T1Gd may be an early biomarker for OA.
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Affiliation(s)
- P Neuman
- Department of Orthopedics, Clinical Sciences, Malmö, Lund University, Sweden.
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Siversson C, Tiderius CJ, Neuman P, Dahlberg L, Svensson J. Repeatability of T1-quantification in dGEMRIC for three different acquisition techniques: two-dimensional inversion recovery, three-dimensional look locker, and three-dimensional variable flip angle. J Magn Reson Imaging 2010; 31:1203-9. [PMID: 20432357 DOI: 10.1002/jmri.22159] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To evaluate the repeatability of the dGEMRIC (delayed gadolinium enhanced MRI of cartilage) method in osteoarthritis-prone knee joints for three different T1 quantification techniques: two-dimensional inversion recovery (2D-IR), three-dimensional Look-Locker (3D-LL), and three-dimensional variable flip angle (3D-VFA). MATERIALS AND METHODS Nine subjects were examined twice, with a 2-week interval, using all three measurement techniques. Four regions of interest were defined in the central medial and lateral femoral cartilage. The repeatability was evaluated for each measurement technique. For the 3D techniques, the variation between different slices was also evaluated. RESULTS Repeatability expressed by root-mean-square coefficient of variation (CV(RMS)) showed similar results for 2D-IR and 3D-LL (5.4-8.4%). For 3D-VFA CV(RMS) was higher (9.3-15.2%). Intraclass correlation coefficient showed both 2D-IR and 3D-LL reliability to be moderate, while 3D-VFA reliability was low. Inter-slice CV(RMS) and ICC was of the same magnitude as the repeatability. No clear differences could be interpreted between the condyles. CONCLUSION Both 2D-IR and 3D-LL perform well in generating repeatable dGEMRIC results, while 3D-VFA results are somewhat inferior. Furthermore, repeatability results in this study are similar to previously published results for healthy subjects. Finally, the positioning of the analyzed images is crucial to generate reliable repeatability results.
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Affiliation(s)
- Carl Siversson
- Department of Radiation Physics, Lund University, Malmö, Sweden.
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17
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Tiderius CJ. Another step towards the understanding of the earliest stages of osteoarthritis. Osteoarthritis Cartilage 2009; 17:1534-5. [PMID: 19747580 DOI: 10.1016/j.joca.2009.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 07/15/2009] [Accepted: 08/24/2009] [Indexed: 02/02/2023]
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Siversson C, Tiderius CJ, Dahlberg L, Svensson J. Local flip angle correction for improved volume T1-quantification in three-dimensional dGEMRIC using the look-locker technique. J Magn Reson Imaging 2009; 30:834-41. [DOI: 10.1002/jmri.21906] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ericsson YB, Tjörnstrand J, Tiderius CJ, Dahlberg LE. Relationship between cartilage glycosaminoglycan content (assessed with dGEMRIC) and OA risk factors in meniscectomized patients. Osteoarthritis Cartilage 2009; 17:565-70. [PMID: 19058980 DOI: 10.1016/j.joca.2008.10.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Accepted: 10/22/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To study the relationship between cartilage integrity, assessed with [delayed Gadolinium-Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC)] and epidemiologic risk factors for knee osteoarthritis (OA) in meniscectomized patients. METHODS Body mass index (BMI) was calculated in 45 patients (16 women), mean age 46, who underwent an arthroscopic medial meniscectomy 1-6 years earlier. The cartilage glycosaminoglycan (GAG) content was estimated by dGEMRIC Index and tests of isokinetic muscle strength and functional performance (one-leg hop test) were conducted. RESULTS BMI ranged from 20.0 to 34.3 (mean: 26.5). The dGEMRIC Index was 14.4% lower in the medial index compartment (374+/-61 ms, mean+/-SD) than in the lateral reference compartment (437+/-59 ms, mean+/-SD) (P<0.001). The dGEMRIC Index of the medial diseased compartment correlated positively with both knee flexor (r=0.50, P=0.001) and knee extensor strength (r=0.47, P=0.001) relative to body weight and with the one-leg hop test (r=0.42, P=0.004). Furthermore, a negative correlation was found between the dGEMRIC Index of the medial compartment and BMI (r=-0.35, P=0.019). No significant correlations were found in the lateral reference compartment. CONCLUSION The lower dGEMRIC Index of the medial compartment suggests decreased cartilage GAG content after medial meniscectomy, indicating an early stage OA. Furthermore, results suggest that overweight is a factor that deteriorates cartilage, whereas strong and co-ordinated thigh muscles may have a protective effect on the cartilage integrity.
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Affiliation(s)
- Y B Ericsson
- Department of Orthopedics, Malmö University Hospital, Lund University, SE-205 02 Malmö, Sweden
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Tiderius CJ, Tjörnstrand J, Akeson P, Södersten K, Dahlberg L, Leander P. Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC): intra- and interobserver variability in standardized drawing of regions of interest. Acta Radiol 2004; 45:628-34. [PMID: 15587420 DOI: 10.1080/02841850410008379] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To establish the reproducibility of a standardized region of interest (ROI) drawing procedure in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC). MATERIAL AND METHODS A large ROI in lateral and medial femoral weight-bearing cartilage was drawn in images of 12 healthy male volunteers by 6 investigators with different skills in MRI. The procedure was done twice, with a 1-week interval. Calculated T1-values were evaluated for intra- and interobserver variability. RESULTS The mean interobserver variability for both compartments ranged between 1.3% and 2.3% for the 6 different investigators without correlation to their experience in MRI. Post-contrast intra-observer variability was low in both the lateral and the medial femoral cartilage, 2.6% and 1.5%, respectively. The larger variability in lateral than in medial cartilage was related to slightly longer and thinner ROIs. CONCLUSION Intra-observer variability and interobserver variability are both low when a large standardized ROI is used in dGEMRIC. The experience of the investigator does not affect the variability, which further supports a clinical applicability of the method.
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Affiliation(s)
- C J Tiderius
- Department of Orthopedics, Malmö University Hospital, Lund University, Malmö, Sweden
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Dahlberg L, Roos E, Svensson J, Leander P, Tiderius C. Arthritis Res Ther 2003; 5:168. [DOI: 10.1186/ar969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Tiderius CJ, Olsson LE, de Verdier H, Leander P, Ekberg O, Dahlberg L. Gd-DTPA2)-enhanced MRI of femoral knee cartilage: a dose-response study in healthy volunteers. Magn Reson Med 2001; 46:1067-71. [PMID: 11746570 DOI: 10.1002/mrm.1300] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The negatively charged contrast agent Gd-DTPA2- distributes inversely to the cartilage fixed charged density. This enables structural cartilage examinations by contrast-enhanced MRI. In line with the development of a clinically applicable protocol for such examinations, this study describes the temporal pattern of Gd-DTPA2- distribution in femoral knee cartilage at three different doses in healthy volunteers. Nineteen volunteers (ages 21-28 years) were examined with a 1.5T MRI system. Quantitative relaxation rate measurements were made in weight-bearing central parts of femoral cartilage using sets of five turbo inversion recovery images with different inversion times. The cartilage was analyzed before and four times (1-4 h) after an intravenous injection of Gd-DTPA2- at single, double, and triple doses: 0.1, 0.2, and 0.3 mmol/kg body weight, respectively. The increase in R1 postcontrast was linearly dose-related at all times. The highest R1 values were registered at 2 and 3 h postcontrast, suggesting 2 h to be optimal in the clinical situation. The triple dose indicated a subtle compartmental difference in men, with higher contrast distribution medially than laterally. Results suggest that the triple dose is needed to detect minor cartilage matrix differences.
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Affiliation(s)
- C J Tiderius
- Department of Orthopedics, Malmö University Hospital, Lund University, Malmö, Sweden
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Tiderius CJ, Landin L, Düppe H. Decreasing incidence of fractures in children: an epidemiological analysis of 1,673 fractures in Malmö, Sweden, 1993-1994. Acta Orthop Scand 1999; 70:622-6. [PMID: 10665730 DOI: 10.3109/17453679908997853] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The incidence of fractures in children in the city of Malmö, Sweden, almost doubled between 1950 and 1979. To see whether a further increase had occurred, we carried out an epidemiological analysis of fractures among children 0-16 years in Malmö 1993-1994. During the study period, 1,673 fractures occurred in 1,610 children. The commonest fracture location was the distal forearm (26%), followed by the phalanges of the hand (16%) and the clavicle (9%). The annual fracture incidence was 235/10(4) in boys, 149/10(4) in girls and 193/10(4) for both genders. This means a decrease in the annual fracture incidence by 9% since 1975-1979. The decrease was not associated with any specific type of fracture or etiological factor. Fractures of the distal forearm among girls were an exception to the general decline, having increased by one third since 1975-1979, which might be explained by the fact that today girls participate to a greater extent in the same sports as boys.
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Affiliation(s)
- C J Tiderius
- Department of Orthopedics, Malmö University Hospital, Sweden.
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