Beyond the bones and joints: a review of ligamentous injuries of the foot and ankle on 99mTc-MDP-SPECT/CT

^99mTc-MDP-single photon emission computed tomography (SPECT)/CT has established itself as a useful modality in the assessment of the painful foot and ankle, owing to its ability to depict anatomical and functional information simultaneously. Despite its growing popularity, much of the literature describing the utility of ^99mTc-MDP-SPECT/CT of the foot and ankle is limited to osseous and articular pathology, with descriptions of ligamentous pathology limited to just a handful of cases. Though assessment of soft tissues using a combination of bone tracer and CT is limited, with a sound understanding of the regional anatomy, it is certainly within the scope of ^99mTc-MDP-SPECT/CT to accurately identify ligamentous injuries based on focal tracer uptake patterns and suspected ligamentous injuries should be reported as such. This article provides a case-based pictorial review of the ^99mTc-MDP-SPECT/CT appearances of the various ligamentous injuries of the foot and ankle with case examples and MRI correlation where available, most of which have yet to be described. The typical patterns of bone tracer uptake and associated CT abnormalities that may be observed are discussed.

Neurological Nuance: Hodgkin lymphoma presenting with Guillain-BarrÉ syndrome

INTRODUCTION

Hodgkin lymphoma (HL) is a common lymphoid malignancy rarely associated with Guillain-Barré syndrome (GBS). In most cases, GBS does not precede HL.

METHODS

We describe a patient with acute inflammatory demyelinating polyneuropathy who fulfilled criteria for GBS that heralded undiagnosed HL.

RESULTS

Cerebrospinal fluid (CSF) studies revealed albuminocytologic dissociation with significant protein elevation (250 mg/dl). The patient worsened during intravenous immunoglobulin (IVIg) therapy. Constitutional symptoms with elevated inflammatory markers prompted further investigation, and imaging revealed an anterior mediastinal mass confirmed on biopsy to be HL. Chemotherapy yielded early clinical improvement.

CONCLUSIONS

GBS preceding HL is rare, and this case highlights the importance of considering HL in the setting of GBS. Marked elevations in CSF protein, ongoing deterioration despite administration of IVIg, and constitutional symptoms with elevated inflammatory markers may be clues to possible HL-induced GBS. Muscle Nerve 55: 601-604, 2017.

Bone Mineral Density Changes in the Hip and Spine of Men and Women 1-Year After Primary Cemented Total Knee Arthroplasty: Prospective Cohort Study

This study evaluated age- and sex-adjusted changes in total hip and spine bone mineral density (BMD) within 1 year of total knee arthroplasty (TKA) using a prospective, longitudinal cohort with a one-year follow-up. Preoperatively, subjects underwent routine bone mineral densitometry of their hip and spine, which was repeated 12 months postoperatively. Of 108 subjects, 97 (90%) completed BMD testing. Total hip BMD decreased significantly over time (1.80% change, P<0.001) with females losing more than males (P<0.001). The pattern was similar, but attenuated in the spine. Subjects undergoing primary cemented TKA had significant bone loss in the hip within 12 months, beyond that expected with age.

Acute Osteochondral Fractures in the Lower Extremities - Approach to Identification and Treatment

Chondral and osteochondral fractures of the lower extremities are important injuries because they can cause pain and dysfunction and often lead to osteoarthritis. These injuries can be misdiagnosed initially which may impact on the healing potential and result in poor long-term outcome. This comprehensive review focuses on current pitfalls in diagnosing acute osteochondral lesions, potential investigative techniques to minimize diagnostic errors as well as surgical treatment options. Acute osteochondral fractures are frequently missed and can be identified more accurately with specific imaging techniques. A number of different methods can be used to fix these fractures but attention to early diagnosis is required to limit progression to osteoarthritis. These fractures are common with joint injuries and early diagnosis and treatment should lead to improved long term outcomes.

Anatomical distribution of vertebral fractures: comparison of pediatric and adult spines

SUMMARY

We compared the distribution of vertebral fractures in adults and children and found that fractures occurred in different locations in the two age groups. This likely relates to the different shape of the immature spine.

INTRODUCTION

We hypothesized that the anatomical distribution of vertebral fractures (VF) would be different in children compared to adults.

METHODS

We compared the distribution of VF defined using the Genant semi-quantitative method (GSQ method) in adults (N = 221; 545 fractures) and in children early in the course of glucocorticoid therapy (N = 44; 94 fractures).

RESULTS

The average age in the adult cohort was 62.9 years (standard deviation (SD), 13.4 years), 26% was male, the mean lumbar spine Z-score was -1.0 (SD, 1.5), and the corresponding T-score was -2.4 (SD, 1.4). The pediatric cohort median age was 7.7 years (range, 2.1-16.6 years), the mean lumbar spine Z-score was -1.7 (SD, 1.5), 52% was male, and disease categories were acute lymphoblastic leukemia (66%), rheumatological conditions (21%), and nephrotic syndrome (14%). The VF distribution was biphasic in both populations, but the peaks differed in location. In adults, the peaks were at T7/T8 and at T12/L1. In children, the focus was higher in the thoracic spine, at T6/T7, and lower in the lumbar spine, at L1/L2. When children were assessed in two age-defined sub-groups, a biphasic VF distribution was seen in both, but the upward shift of the thoracic focus to T6 was observed only in the older group, with the highest rates of fracture present between ages 7 and 10 years.

CONCLUSIONS

These results suggest that the anatomical distribution of VF differs between children and adults, perhaps relating to the different shape of the immature spine, notably the changing ratio of kyphosis to lordosis.

The accuracy of clinical kyphosis examination for detection of thoracic vertebral fractures: comparison of direct and indirect kyphosis measures

OBJECTIVE

To compare the accuracies of two simple physical examination maneuvers for detecting the presence of thoracic vertebral fractures (VF) diagnosed by radiography: direct measurement of kyphosis angle (KA, in degrees) and indirect measurement using wall-occiput distance (WOD, in cm).

METHODS

Subjects were 280 women (average age, 54.5 years; range, 18-92) referred for assessment of osteoporosis. KA was measured from T4 to T12 using a digital inclinometer while WOD was measured with the patient in a standardized position. VF were diagnosed on radiographs using semi-quantitative morphometry.

RESULTS

KA and WOD were moderately correlated (r = 0.72, p<10(-11)). KA increased by 3.7(o) (95% CI, 2.6-4.8(o)) for each VF (p = 4x 10(-11)) and WOD rose 1.3 cm (95% CI, 0.8-1.7 cm) per VF (p = 2 x 10(-11)). The areas under the receiver operating characteristic curves were 0.72 (95% CI, 0.65-0.79) for KA and 0.76 (95% CI, 0.69-0.82) for WOD, which were not significantly different (p = 0.13).

CONCLUSIONS

Given similar performances of direct and indirect measures of kyphosis, we propose that WOD should be used in clinical practice, with a clinical threshold of WOD>4.0 cm as an indication to consider spine radiography. At this WOD threshold, sensitivity was 41% (95% CI, 31-52%) and specificity was 92% (95% CI, 87-95%). WOD should be considered for use in the clinical assessment of osteoporosis patients.

Vertebral fractures and role of low bone mineral density in Crohn's disease

BACKGROUND & AIMS

Vertebral fractures in Crohn's (CD) patients with low bone mineral density (BMD) have been documented as between 14%-22%. Vertebral fractures in CD patients with normal BMD have not been reported. The objectives were to identify the prevalence of vertebral fractures in CD patients and associated predictive factors.

METHODS

Two hundred twenty-four CD patients underwent vertebral BMD analysis and radiographs. Fractures were identified by using quantitative height reduction morphometry, and severity was assessed by spinal fracture index.

RESULTS

Mean age was 40.6 +/- 11.0 years. Sixty percent reported corticosteroid use during the preceding year. Forty-five of 224 (20.0%) patients had 88 vertebral fractures. Sixteen of 45 patients with vertebral fractures had normal BMD (19.0% of all patients with normal BMD). Analysis of patients with or without vertebral fractures did not demonstrate significant differences in BMD or in corticosteroid use. Linear regression analysis demonstrated that elevations in body mass index, C-reactive protein, and parathyroid hormone were significantly predictive of vertebral fractures (r = 0.415, P < .05), and height reduction was >20% (r = 0.417, P < .05).

CONCLUSIONS

This study demonstrates that vertebral fractures in CD patients occur with an equal frequency in those with low and with normal BMD, regardless of corticosteroid use. The mean age of CD patients with vertebral fractures was much lower than that reported in the general population for these fractures. Elevations in body mass index and C-reactive protein and parathyroid hormone levels were predictive of vertebral fractures.

The accuracy of historical height loss for the detection of vertebral fractures in postmenopausal women

Historical height loss (HHL) can be calculated as the difference between a patient's tallest recalled height (TRH) and the current measured height (MH). We have examined the accuracy of HHL as a clinical test for the detection of prevalent vertebral fractures. Subjects were postmenopausal women aged 50 or older who had been referred for specialist assessment of osteoporosis risk (n=323; average age 66.0+/-9.2 years; range 50-92 years). MH was determined using a wall-mounted stadiometer. The presence of prevalent vertebral fractures was assessed by radiographic morphometry, with fracture defined as a vertebral height ratio<0.8. The positive likelihood ratio (LR+) for fracture was relatively flat until HHL>6.0 cm. With HHL from 6.1 to 8.0 cm, the LR+ was 2.8 [95% confidence interval (95%CI), 1.3, 6.0]. When HHL was >8.0 cm, the LR+ was 9.8 (95% CI, 3.0, 31.8). The area under the receiver operating characteristics curve for the ability of HHL to detect fracture was 0.66 (95% CI, 0.59, 0.72). At HHL>6.0 cm, sensitivity was 30% (95% CI, 22, 37%), and specificity was 94% (95% CI, 90, 97%). The positive predictive value was relatively low across a range of theoretical prevalence, rising above 80% only at very high prevalence rates (>50%). In contrast, the negative predictive value was high at the prevalence rates seen in most clinical practice, and dropped below 80% only when the prevalence exceeded 25%. This study shows that HHL<or=6.0 cm rules out prevalent vertebral fracture with a high degree of accuracy; patients with HHL>6.0 cm should have spine radiographs to examine for the presence of vertebral fractures.

Incidental Vertebral Fractures Discovered With Chest Radiography in the Emergency Department

BACKGROUND

Vertebral fractures are common and usually an indication for osteoporosis treatment. However, screening is not recommended, and many fractures go undetected. Our objectives were to determine the utility of chest radiographs for detecting previously unrecognized vertebral fractures; document rates of recognition; and evaluate osteoporosis treatments.

METHODS

In 2001, we conducted a cohort study in a random sample of 500 patients older than 60 years who presented to our emergency department and underwent chest radiography for any indication. The primary outcome was prevalence of moderate-to-severe vertebral fractures determined by independent radiograph review using validated semiquantitative techniques. Secondary outcomes were rates of fracture recognition according to official radiologists' reports and rates of osteoporosis diagnosis and treatment. We conducted multivariable regression analyses to determine correlates of study-defined and officially reported fractures.

RESULTS

We excluded 36 patients with inadequate radiographs and 5 for other reasons. Mean age was 75.2 years; 47% were women; and 80% were white. The prevalence of moderate-to-severe vertebral fractures according to independent review was 72 (16%) of 459; 29 (40%) of these fractures were not recorded in the official radiologists' report (kappa = 0.64; 95% confidence interval [CI], 0.53-0.75). A history of osteoporosis was the only independent correlate of having a vertebral fracture identified by independent review (adjusted odds ratio [OR], 2.18; 95% CI, 1.14-4.17) or by official report (adjusted OR, 4.97; 95% CI, 0.95-25.86). Of the 72 patients with fractures, only 18 (25%) had histories of osteoporosis or received osteoporosis medications.

CONCLUSIONS

One in 6 elderly patients who underwent chest radiography in our emergency department had clinically important vertebral fractures. Nevertheless, only 43 (60%) of these fractures were reported, and only 25% of patients with fractures received a diagnosis of or treatment for osteoporosis.

Randomized trial of etidronate plus calcium and vitamin D for treatment of low bone mineral density in Crohn's disease

BACKGROUND & AIMS

Crohn's disease causes an increase in osteopenia and osteoporosis. This study assessed the efficacy of adding etidronate to calcium and vitamin D supplementation for treatment of low bone mineral density in Crohn's disease.

METHODS

One hundred fifty-four patients with Crohn's disease with decreased bone mineral density, determined by using dual-energy x-ray absorptiometry, were randomly assigned to receive etidronate (400 mg orally) or not for 14 days; both groups were then given daily calcium (500 mg) and vitamin D (400 IU) supplementation for 76 days. This cycle was repeated 8 times during a period of 24 months. Biochemical characteristics and bone mineral densities were assessed at 6, 12, and 24 months.

RESULTS

After 24 months bone mineral density significantly increased from baseline in both the etidronate- and the non-etidronate-treated groups (both groups receiving calcium and vitamin D supplementation) at the lumbar spine (P < .001), ultradistal radius (P < .001), and trochanter (P = .004) sites, but not at the total hip. The increase in bone mineral density was similar in each treatment group. No bone mineral density differences were found when groups were analyzed according to gender, corticosteroid use, bone mineral density at baseline, or age.

CONCLUSIONS

Low bone mineral density is frequently associated with Crohn's disease. Supplementation with daily calcium and vitamin D is associated with increases in bone mineral density. The addition of oral etidronate does not further enhance bone mineral density.

Bones and Crohn's: risk factors associated with low bone mineral density in patients with Crohn's disease

Previous studies have confirmed that the prevalence of decreased bone mineral density is elevated in patients with inflammatory bowel disease. The objective of the current study was to determine the prevalence of osteopenia and osteoporosis in a cross-sectional outpatient population of 242 adult patients with Crohn's disease and to determine which clinical characteristics and serum and urine biochemical factors might be predictive of bone loss. Thirty-seven percent had normal bone density, 50.0% were osteopenic, and 12.9% were osteoporotic. Among the sites used to diagnose low bone mineral density, the femoral neck demonstrated the highest prevalence of osteopenia and the ultra-distal radius the highest prevalence of osteoporosis. However, low bone mineral density at one site was always predictive of low bone mineral density at the other. Corticosteroid use during the year before assessment was found to be consistently predictive of low bone mineral density in males but not in females. In contrast, low body mass index and high platelet counts were consistently predictive of low bone mineral density in females but not in males. Disease location, smoking, and age were not predictive of changes in bone mineral density.

Underreporting of vertebral fractures on routine chest radiography

OBJECTIVE

Osteoporosis is underdiagnosed and therefore undertreated. We determined the potential usefulness of chest radiography for detecting clinically important vertebral fractures by performing semiquantitative reviews and quantitative digital morphometry on 100 routine chest radiographs taken in the emergency department and comparing the yield of these independent reviews with official radiology reports.

MATERIALS AND METHODS

One hundred randomly selected chest radiographs of patients 60 years or older who presented to the emergency department of a tertiary care hospital were evaluated. Radiographs were selected without knowledge of the presenting complaint and were independently reviewed by two board-certified radiologists and a radiology resident. A validated semiquantitative method was used to assess lateral chest radiographs for vertebral fracture. In addition, quantitative digital morphometry was undertaken. A clinically important vertebral fracture was defined as one that was at least moderate to severe (loss of height >or=> 25%).

RESULTS

Mean age of the population was 75 years, 47% were women, and 46% were admitted to the hospital. According to the reference radiologist, prevalence of moderate to severe vertebral fractures was 22%. Simple agreement was 87-88% among reviewers; kappa values were moderate (0.56-0.58). The greatest agreement was between the reference standard radiologist and quantitative digital morphometry (89% agreement; kappa = 0.67). Only 55% (12/22) of vertebral fractures we identified were mentioned in the official radiology reports.

CONCLUSION

Chest radiography has potential as a screening tool for revealing previously undiagnosed vertebral fractures, although in this study only half of moderate to severe fractures that we identified were mentioned in official reports.

Autosomal recessive (infantile) polycystic kidney disease demonstrated by Tc-99m DMSA renal imaging

A neonate with infantile polycystic kidney disease underwent Tc-99m DMSA imaging. The pattern of uptake in infantile polycystic disease is different from the multiple cystic lesions reported in the literature for adult polycystic kidney disease. The infantile pattern of uptake shows large kidneys with diffuse, symmetric localization of the radiopharmaceutical, which seems to be characteristic and may be pathognomonic of the disease process.

Proterozoic stromatolitic microbiotas of the 1400-1500 Ma-old Gaoyuzhuang formation near Jixian, northern China

Two communities of diverse, well-preserved, fossil prokaryotic microorganisms have been discovered in petrographic thin sections of carbonaceous black chert from the ca. 1400-1500 Ma-old Gaoyuzhuang Formation at the stratotype section of the "Sinian Suberathem" near Jixian, northern China. One of these communities is preserved in bedded, essentially flat-laminated, stromatolitic chert; the other occurs in silicified conical stromatolites of the forms Conophyton cylindricum and C. garganicum. The Gaoyuzhuang cherts comprise one of the new microfossiliferous deposits now known from the Precambrian of China; the permineralized microbiotas they contain are among the first such stromatolitic assemblages to be discovered in the Sinian stratotype section.