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Transient “Femoral blaze” phenomenon in patients treated with Corail® Cementless Primary Total Hip Arthroplasty: an observational cohort study & theoretical evaluation of possible causes

June 2017

Conference: ESSR 2017

Authors:

Danoob Dalili

South West London Elective Orthopaedic Centre (SWLEOC)

Mohit Bansal

Guy's and St Thomas' NHS Foundation Trust

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ABSTRACTS

24th Annual Scientific Meeting of the European Society

of Musculoskeletal Radiology (ESSR), Bari/Italy, June 15-17, 2017

Friday, June 16

Scientific Paper Session –Hip

Leg lengthening and femoral-offset reduction after total hip

arthroplasty: where is the problem related –stem or cup positioning?

B. S. Al-Amiry

,A.Sayed-Noor

;

Stockholm/SE,

Sundsvall/SE

Purpose: Restoration of the biomechanical forces around the hip with

appropriate femoral offset(FO) and leg length is an important goal in total

hip arthroplasty (THA)as it improves functional outcome. The purpose of

this prospective cohort study is to analyse whether the problem of post-

operative leg lengthening and femoral-offset (FO) reduction is related to

the femoral stem or acetabular cup positioning or both.

Methods and Materials: Between September 2010 and April 2013, 172

patients with unilateral primary osteoarthritis treated with THA were in-

cluded. Postoperative leg-lengh discrepancy (LLD) and global FO (sum-

mation of cup and femoral offset) were measured by two observers using

a standardized protocol for evaluation of antero-posterior plain hip radio-

graphs. Patients with postoperative leg lengthening ≥10 mm (n=41) or

with reduced global FO > 5 mm (n=58) were further studied to investigate

whether the leg lengthening and global FO reduction was related to the

positioning of the femoral stem and/or the acetabular cup. This was

achieved by comparing the stem and cup length of the operated side with

the contralateral sidein the lengthening group, and by comparing the stem

and cup offset of the operated side with the contralateral side in the FO

reduction group. We evaluated also the inter and intraobserver reliability

of the radiological measurements.

Results: Both observers found that leg lengthening was related to the

stem positioning while FO reduction was related to the positioning of

both the femoral stem and acetabular cup. Both interobserver reliability

and intraobserver reproducibility were moderate to excellent (intra-class

correlation co-efficient, ICC ≥0.69).

Conclusion: Post THA leg lengthening was mainly caused by improper

femoral stem positioning while global FO reduction resulted from im-

proper positioning of both the femoral stem and the acetabular cup.

CT-based range-of-motion measurements in patients with dislocated

and non-dislocated total hip arthroplasties

R. H. H. Wellenberg

,J.vanOsch

,S.Witvoet

,E.Nieboer

,M.Maas

H. B. Ettema

,M.F.Boomsma

;

Amsterdam/NL,

Zwolle/NL,

Groningen/NL,

Nigtevecht/NL

Purpose: To obtain range-of-motion (ROM) measurements in patients with

total hip arthroplasties (THA) on CT images. In order to identify patients at

risk for dislocation, ROM was calculated and compared in two different

groups of THA patients: with and without known dislocation. Optimal size

and orientation of hip prosthesis components can be determined in order to

reduce the number of dislocation related THA revisions or aid in planning

THA revisions.

Methods and Materials: CT images of 48 patients were analysed: 23

dislocated THAs and 25 non-dislocated THAs. CT images were used to

measure: the neck diameter and head diameter (28 or 32 mm), angles A

(max angle of the radius movement in the cup), θ(max angle of the neck

of the prosthesis in the cup), α(initial abduction/inclination of the cup), β

(anterior opening angle of the cup), a (angle of the neck of the prosthesis

relative to the horizontal plane) and b (anteversion angle of the neck

around the vertical axis). Pearson scores were obtained for the manual

CT measurements. Using these measurements as input for a geometric

model we calculated the ROM expressed in flexion, extension, external

rotation, internal rotation, abduction and adduction. Corrections were

applied for knee orientation.

Results: CT measurements for dislocated and non-dislocated THAs were

169.73° versus 172.64° for angle A (p=0.063), 110.12° versus 117.78°

for angle θ(p=0.002), 13.96 mm versus 13.06 mm neck diameter

(p=0.005), 22 out of 23 versus 23 out of 25 with 28 mm head diameter

(p=0.605), 43.70° versus 46.33° for angle α(p=0.392), 20.55° versus

23.09° for angle β(p=0.584), 46.52° versus 48.72° for angle a

(p=0.068) and 17.36° versus 8.36° for angle b (p=0.003) respectively.

Average Pearson scores between observers and within observers for the

CT measurements were 0.93 and 0.87 respectively. Calculated ROM

values for dislocated and non-dislocated THAs were 117.54° versus

119.31° for flexion (p=0.628), 31.71° versus 45.67° for extension

(p=0.204), 39.18° versus 49.33° for external rotation (p=0.110),

125.80° and 124.11° for internal rotation (p=0.942), 57.86° and 63.51°

for abduction (p=0.049) and 53.45° and 51.67° for adduction (p=0.502)

respectively.

Conclusion: Based on CT measurements, a smaller oscillation angle θ,a

greater neck diameter and a greater anteversion angle of the neck of the

prosthesis around the vertical axis (angle b) seem to increase the occur-

rence of dislocations in patients with THAs. Furthermore based on ROM

calculations, smaller abduction angles may also increase the risk of dis-

locations.

3D printing (3DP) applications in complex revision hip arthroplasty

(CRHA): A prospective nonrandomised controlled observational co-

hort study

D. Dalili, N. Byrne, Z. Shah, M. J. Bankes, M. George, A. Isaac; London/

Purpose: To assess the value of 3D models of the femoroacetabular joint

in surgical care, utilising current preoperative cross-sectional imaging

modalities. Our institution is a tertiary referral centre for patients with

complex hip pathology and is one of the largest specialists young adult

hip units in the country.

Skeletal Radiol (2017) 46:845–871

DOI 10.1007/s00256-017-2619-4

Methods and Materials: Preoperative CT data from 10 patients listed for

CRHA were prospectively collected and digitally reconstructed using

3DP software.

All revision cases were discussed amongst three experienced hip-sur-

geons and a musculoskeletal radiologist, who were asked to complete a

written short questionnaire. The level of complexity of the cases was

ascertained by consensus amongst the surgeons.

Thereafter, they were presented with the 3D modeland asked to repeat the

questionnaire.

The details of surgery, cost of the prosthesis and total operative savings,

length of hospital stay and rehabilitation notes were recorded.

Results: Our pilot study has proven to:

1-Shorten the operative time by 30-90 minutes, reducing the costs of

theatre & staff time, allowing more procedures to be performed on the

day, thus reducing the waiting lists.

2- Reduce the excess of pre-ordered prostheses, lowering shelf-loan costs

and overall operative costs.

3-Subjectively improve patient outcomes through reduced anaesthetic

time, intraoperative manipulations with associated blood loss and

bruising.

4- Improve the surgeon’s confidence in preoperative planning through the

choice of appropriate prosthesis, position and trajectory for screw

placement.

Conclusion: The configuration of the patient’s hip joint is often distorted

due to mechanical failure, the reaction at the bone-primary prosthesis’

interface, and underling osteoporosis and hardware failure with time.

Appreciation of the residual bonyanatomy, boneloss, displacementof the

surrounding soft tissues and the 3D spatial relationships between all four

is critical to surgical planning. 3DP when married with medical imaging,

allows the reproduction of anatomy in a patient-specific model, thus

capturing the radiologist’s expert understanding of the CT scan within

an immediately accessible form, that the surgeon can hold in their hands.

These models represent a true size of the patient’s anatomy. 3DP models

can be produced quickly and allow for enhanced visualisation and phys-

ical interaction. This is clearly of great benefit for technically challenging

cases such as when there is anatomic variance, complex fracture patterns

or in revision reconstruction.

The ability to hold a scale model allows for the simulation and then

practice of the surgical technique, simulating the procedure and trialling

a range of solutions prior to entering the operating theatre.

A more robust research study is currently underway.

Transient “Femoral blaze”phenomenon in patients treated with

Corail®Hip arthroplasty: an observational cohort study & theoretical

evaluation of possible causes

D. Dalili,M. Bansal, M. J. Bankes, M. George, Z. Shah, A. Isaac;

London/UK

Purpose: To evaluate & describe, the transient, increased uptake phe-

nomenon observed around the uncemented femoral component of the

prosthesis in a proportion of patients who underwent Hip arthroplasty

using the Corail® hip system, in the absence of radiographic findings

on serial follow up.

To propose possible causes for this phenomenon based on the current

literature, the clinical, radiographic, serological and scintigraphic find-

ings, in a cohort of patients presenting to a tertiary referral centre for

primary & revision hip replacement surgery.

Methods and Materials: Evaluation of hip imaging (radiographic, cross-

sectional and scintigraphic) of patient who underwent Hip arthroplasty

using the Corail® hip system from 2008 to date in a tertiary referral centre

for primary and revision hip replacement surgery.

The criteria for patient selection, preoperative and postoperative imaging,

clinical outcome scores and clinical findings were analysed.

Correlation between the radiographic and scintigraphic findings on serial

imaging was scrutinised.

Follow up to a maximum of 9 years was documented.

Results: Transient focal increased uptake around the margins of the fem-

oral stem was observed in a proportion of patients presenting with focal

pain symptoms on dynamic movement of the ipsilateral hip. There was

complete reversal of the clinical symptoms and radiological findings on

serial imaging (3-9months). In patients with unresolved symptoms &

unusual scinitigraphic findings, other causes including infection and/or

loosening was detected and treated successfully.

Conclusion: The concept of an extensive hydroxyapatite (HA) coating

for the fixation of a specifically tapered femoral stem (Corail®) was

introduced 25 years ago. The aim was to achieve durable biological fix-

ation while preserving normal periprosthetic bone activity. The value of

uncemented fixation using HA-coated implants is widely accepted

amongst scholars. The Corail® system offers validated superior

osteointegration around the femoral stem when compared to other sys-

tems, partially due to the lack of medullary reaming required prior to

placement of the femoral stem component. On histological evaluation,

there is absence of the expected fibrous-interface between the native bone

and the prosthesis with relatively silent radiographic findings on periop-

erative and short term follow up radiographs.

Knowledge of these characteristic transient findings, should alert the team

to exclude infection in the first instance, therafter monitoring the patient

with serial imaging, rehabilitation and clinical follow up. This could

reduce the incidence of excessive interventions and encourage patients

to continue with their rehabilitation and return to normal levels of phys-

ical activity.

Reference: Jean-Pierre Vidalain. Twenty-year results of the cementless

Corail stem. International Orthopaedics (SICOT) (2011) 35:189–194

DOI 10.1007/s00264-010-1117-2

The relationship between femoral neck anteversion and low back

pain in patients with severe unilateral primary hip osteoarthritis

A. Piazzolla, G. Solarino, D. Bizzoca, C. Campagna, P. Pignataro, G.

Angelelli, B. Moretti; Bari/IT

Purpose: This study aims to assess the relationship between Femoral

Neck Anteversion (FNA) and Low Back Pain (LBP) in patients under-

going Total Hip Replacement (THR) for unilateral severe primary hip

osteoarthritis (HOA).

Methods and Materials: 91 patients were recruited. Inclusion criteria:

grade 5 or 6 unilateral HOA according to Turmezei and Harris Hip score

(HHS) <60. Exclusion criteria: secondary hip osteoarthritis; previous sur-

gery of the spine, hip or knee; scoliosis; spondylolisthesis; history of

spine fractures; any spine infections; any contraindications to CT;

BMI>30. Patients were divided into two groups according to the presence

(Group-A) or absence of concomitant LBP (Group-B).

All the patients underwent, preoperatively and at 6 months follow-up, a

hip CT to evaluate FNA, Acetabular Anteversion (AA) and Combined

Anteversion (CA= FNA+AA). ΔFNA, ΔAA and ΔCA were calculated

as the differences between the arthritic hip and the normal hip angles. The

health-related quality of life (HRQoL) was evaluated at baseline and at

follow-up using Visual Analogue Scale (VAS), HHS, Oswestry Disability

Index (ODI), Roland-Morris Disability Questionnaire (RM) and Short

Form Health Survey (SF-36). The paired ttest, the unpaired ttest and

the Pearson correlation test were performed.

Results: At baseline, in Group-A a significant difference between arthrit-

ic FNA and normal hip FNA was recorded, while no differences were

846 Skeletal Radiol (2017) 46:845–871

found in AA between the two hips. A close correlation was ob-

served between ΔFNA and Spine-VAS (r=0.788), ODI (r=0.824)

and RM (r=0.775). In Group-B, there was not a significant dif-

ference in FNA and AA between the two hips at baseline. No

significant differences in arthritic hips FNA, AA and CA between

the two Groups were noticed at recruitment. At follow-up, in

Group-A the femoral stem anteversion (FSA) was significantly

lower than the native FNA (p<0.05) and no significant differences

were observed between the FSA and the contralateral hip FNA. In

these patients, a significant improvement of all HRQoL scores

was also recorded.

In Group-B, at follow-up an improvement of HHS, Hip-VAS and SF-36

was observed, while no significant differences between the native arthritic

hip FNA and the FSA were recorded.

Conclusion: Patients with concomitant unilateral HOA and LBP showed

a marked anteverted FNA at the arthritic hip, compared with contralateral

hip. In these patients, the ΔFNA between the two hips is strongly related

to LBP and its correction, through THR, leads to both hip and low back

pain improvement.

The outcomes of hip arthroscopy with cross-sectional, scintigraphic,

sonographic and conventional radiographic correlation: Experience

from a young adult hip centre of excellence

D. Dalili,M. Bansal, N. Khandwalla, Z. Shah, M. George, M. J. Bankes,

A. Isaac; London/UK

Purpose: To analyse the imaging findings in patients presenting with

femoracetabular impingement (FAI), clinically selected for arthroscopy.

To evaluate patient outcomes following primary arthroscopy, based on up

to 48 months follow up.

To assess the range of findings on subsequent imaging.

To establish the requirement for additional image guided interventional

procedures.

Methods and Materials: Analysis of all imaging performed on patients

presenting to our young adult hip unit between January 2013 and

December 2015 (36 months).

Correlation with post procedure clinical notes, subsequent imaging and/or

interventional procedures performed.

Results: 510 adult patients underwent arthroscopy over 36 months. Of

which:

- 84 patients(16.5%) presented with persistent/new pain after 6-12 weeks.

- 426 patients (83.5%) experienced complete resolution of symptoms

within 6-12 weeks from surgery.

- 42 patients (8.24%) had imaging guided injections: 38/42 (7.45%) into

the same hip joint and 4 patients (0.78%) around the psoas tendon

insertion.

- 14 patients (2.75%) required repeat arthroscopy.

- 5 patients (0.98%) had periacetabular osteotomies/reversed

periacetabular osteotomies.

- 17 patients (3.3%) underwent total hip replacement (THR) procedures

within 48 months of arthroscopy.

- The overall incidence of surgery following a primary arthroscopy pro-

cedure was as low as 36/510 patients (7.06%) over a four-year follow up

interval.

Conclusion:

- Patient selection plays a pivotal role in patient outcomes.

- Imaging of FAI is crucial for pre-arthroscopic evaluation of the extent of

impingement for preoperative planning.

- Synovitis is the most frequent cause for post-arthroscopic hip pain. It

was seen in 38/84 patients (45.2%), requiring minimally invasive image

guided interventions to alleviate symptoms.

- Arthroscopy performed in experienced young adult hip units is now a

common procedure, favouring predictable and improved short and long

term outcomes in young adult patients with FAI.

- Minimally invasive hip preserving surgery in cases with FAI, offers

excellent long-term outcomes, compared to previous conventional thera-

pies (early invasive interventions and THR).

3D HRCT measurement of acetabular spatial orientation angles:

standard reconstruction planes proposal for an objective and repro-

ducible evaluation

G. Dilorenzo, A. Colaninno, C. Campagna, V. Favia, A. Spinarelli, B.

Moretti, G. Angelelli; Bari/IT

Purpose: To evaluate the reliability of acetabular version and inclination

measurement on HRCT 3D multi-planar reconstructions based on ana-

tomical defined reference planes, among three different physiopatholog-

ical settings: healthy hip, severe hip osteoarthritis, hip arthroplasty.

Methods and Materials: Between January and December 2016, 177

hips were evaluated with HRCT:

27 healthy patients for a total of 54 healthy hips (group 1);

40 patients affected by severe hip osteoarthritis in a preoperative evalua-

tion for hip arthroplasty (23 bilateral, 17 monolateral),63 hips in total)

(group 2);

60 patient with coxofemoral prosthesis (group 3);

CT scans, performed from L4 to the middle of femoral diaphyses,

were reconstructed on axial planes parallel to the pelvic outlet for

the evaluation of acetabular version angle (AVA),measured be-

tween the acetabular axis and a line tangent to the posterior mar-

gin of both ischiatic tuberosities transposed cranially to the center

of acetabular fossa or acetabular cup. Then coronal reconstruc-

tions were obtained parallel to a reference plane perpendicular

to pelvic outlet and passing through both anterior superior iliac

spines. On these scans acetabular axis inclination angle (AIA) was

then referred to a sagittal plane passing through the center of S1

and pubic symphysis. Two blinded radiologists measured acetab-

ular version and inclination angles.

Mean AVA and AIA values in the three groups were compared using

student T-test.

Cohen’s Kappa was obtained for inter-observer agreement assessment.

Results: Mean AVA was 22, 53° in group 1, 21, 52 ° in group 2 and 18,

47° in group 3. The difference between AVA in group 1 and 3 resulted

statistically significant (p=0,0207). No significant difference in AVAwas

found between group 1 and 2 and between group 2 and 3.

Mean AIAwas 57,32° in group 56,61° in group 2 and 45,73° in group 3.

AIA values in group 3 were significantly different than the other two

groups (p<0,0001). No statistical difference was found between AIA in

group 1 and 2.

Inter-observer agreement was elevated (k=0,83).

Conclusion: Axial and coronal reference planes proposed for HRCT

multi-planar reconstructions allow an accurate, reproducible measure-

ment of acetabular axis version and inclination, in different physiopatho-

logical hip conditions.

Accordingto our data, normal mean AVA and AIA are respectively 22.5°

and 57,3°.

Severe osteoarthritis doesn't modify acetabular axis multiplanar

orientation.

Acetabular cup in hip arthroprostheses shows a different spatial orienta-

tion than anatomical acetabulum, in particular the inclination on the cor-

onal plane. AVA and AIA, obtained on HRCT standardized reconstruc-

tion planes, could be proposed as an evaluation index for correct coxo-

femoral prosthesis implant.

Skeletal Radiol (2017) 46:845–871 847

Ischiofemoral impingement syndrome –the role of MRI in the age

aspect

A. Karpenko, K. K. Kubacheva, I. N. Dutova; St. Petersburg/RU

Purpose: Isсhiofemoral impingment syndrome is one of the manifesta-

tions of chronic pain syndrome non-traumatic, localized in the groin or

buttocks that occurs in middle-aged women. The purpose of this study is

to determine the role of MRI of ballet dancers in different age categories.

Methods and Materials: MRI of the hip joints was performed to 66

patients from 10 to 60 years, 36 of them were ballet dancers with chronic

pain syndrome, and 30 of them were control group. The study was per-

formed on the MRI 1.5 T (Siemens Magnetom Avanto), using a standard

protocol: PD WI FAT SAT, T2 and T1 in 3 planes, with subsequent mea-

surement of ischiofemoral space (IFS) and the quadratus femoris space

(QFS) in the axial plane. In addition, the quadratus femoris muscle was

evaluated for the presence of edema, tear or muscle atrophy. IFS were

measured between ischium tuberosity and the iliopsoas tendon or the lesser

trochanter, the QFS was measured between the postero-medial surface of

the iliopsoas tendon or the lesser trochanter to supero-lateral surface of the

hamstring tendons at the level of attachment to the ischial tuberosity.

Results: 86,1 % of all ballet dancers were women (31 patient), 41,6% (15

patients) were from 10 to 20 years. All ballet dancers had decrease IFS to

0,5-0,7 cm (12 patients –33,3%), to 0,8-1,0 cm (14 patients –42,4%) and

to 1,2-1,4 cm (10 patients –24,3%). In the control group IFS varied from

1,7 to 2,3cm. 32 ballet dancers (88,8%) had edema of quadratus femoris

muscle and decrease QFS, expressed in varying degrees in accordance

with degree of narrowing IFS. The QFS in the control group was 1,3-

1,7cm. 77,7% (28 patients) of ballet dancers had symmetric or asymmet-

ric anteverted heads and femoral necks.

Conclusion: MRI is a highly informative method for detecting

ischiofemoral impingement syndrome in the chronic pain syndrome of

the hip joints of ballet dancers.

Acetabular coverage assessment based on semi-automated 3D-

modelled biplanar radiographs

B. Fritz, C. A. Agten, C. W. A. Pfirrmann, R. Sutter; Zurich/CH

Purpose: The assessment of acetabular coverage is of increasing impor-

tance in the evaluation of young patients with suspected femoroacetabular

impingement or hip dysplasia. However, 3D evaluation of acetabular

coverage based on computed tomography (CT) of the pelvis results in

considerable radiation doses, which should be avoided especially in

young patients. Therefore, we set out to evaluate the potential of 2D

and 3D acetabular coverage assessment based on low-dose biplanar ra-

diograph (BPR) data.

Methods and Materials: The local ethics committee approved this ret-

rospective study. This study consisted of 50 consecutive patients, who

underwent low-dose BPR of the lower extremities including the pelvis

with the EOS-system as well as CT of the pelvis. Based on BPR data,

calculations of the anterior and posterior 2D coverage as well as of the

global 3D coverage of the hip joint were performed using semi-automated

3D-models created by dedicated software packages. Calculations of an-

terior and posterior 2D coverage and global 3D coverage of the hip joint

based on CTserved as the standard of reference. All acetabular coverages

were calculated in the anterior pelvic plane.

Anterior and posterior 2D coverage was defined as the ratio of the

intersected area of the projected anterior or posterior acetabular wall,

respectively, with the projected femoral head area represented by a best

fit circle, in the anteroposterior view. 3D global coverage was defined as

the ratio of the femoral head surface area covered by the acetabulum and

the entire femoral head surface area. General descriptive statistics were

performed and intraclass correlation coefficients (ICC) used to assess

inter-method reliability.

Results: The mean 2D anterior coverage calculated based on BPR was

21.1% (standard deviation [SD] 7.5) compared to 23.9% (SD 8.2) based on

CT. Mean 2D posterior coverage calculations based on BPR were 54.1%

(SD 9.7), compared to 61.4 % (SD 9.6) based on CT. 3D global coverage

calculations based on BPR was 42.7% (SD 6.9), compared to 45.6% (SD

3.6) based on CT. The inter-method reliability was good to very good with

an ICC of 0.829, 0.865 and 0.713 for 2D anterior coverage, 2D posterior

coverage and 3D global coverage calculations, respectively.

Conclusion: Using dedicated semi-automated software, 2D and 3D ace-

tabular coverages can be calculated with good to very good reliability

based on low-dose biplanar radiographs in comparison to CT.

Femoral neck anteversion (FNA): Validation and reproducibility of

two- and three-dimensional (2D and 3D) methods for measurement

on repeated CT examinations

N. Egund

,B.Jacobsen

;

Aarhus C/DK,

Copenhagen/DK

Purpose: To investigate the reproducibility of measurement of the fem-

oral neck anteversion (FNA) angle by repeated CT examinations in dif-

ferent positions of the femur assessing the two most commonly used 2D

methods in comparison with a 3D method.

Methods and Materials: Four dried femurs were repeatedly examined

by CT in eight different positions representing baseline position, 6.0°-7.5°

of flexion, extension, abduction and adduction and 12° internal and ex-

ternal rotation of the hip joint. CT data was imported into a 3D visuali-

zation software allowing visualization of the calculated axes, planes, dis-

tances andangles. Landmarks were by the 3D method defined in 3 planes

and registered by their x, y, z coordinates. FNA was measured by two

different 2D methods using the definition of the femoral neck axis ac-

cording to Tomczak (method-1) and Murphy (method-2), respectively.

By the 3D (method-3), FNA was calculated as the angle between the

two planes containing the long femoral axis and the axis of the femoral

neck and the condylar plane respectively. Two observers performed all

measurements twice. Measurements were compared to geometrically cal-

culated influence of femur positioning.

Results: Inter-observer analysis using Bland-Altman plot showed a 95%

CI for method-1=-4.1°/6.5°, method-2=-1.9°/2.1°, method-3=-1.8°/1.8°.

Almost identical intra-observer reliability. Mean/baseline FNAs by

method-3 were for femur1=22.6°, femur2=22.4°, femur3=26.5°, fe-

mur4=26.8° reproduced within 1.6° in the eight positions. Baseline FNAs

by method-2 were almost the same as for method-3. Baseline FNA by

method-1: femur1=8.0°, femur2 =13.4°, femur3=14.7°, femur4=19.0°.

The maximum difference of FNAs of the 4 femurs by method-1 and 2

for the eight positions varied between 8° and 13°. The resulting influence

of femur positioning by method-2 were in accordance with the calculated

errors: Every 10-mm elevation of the knee (=1.5° of hip flexion) increase

the FNA angle by 1.5°. Similarly, hip extension decrease the FNA. Every

10-mm change of knee positioning towards abduction and adduction re-

spectively decrease and increase FNA with 0.6°.

Conclusion: Measurement of FNA using methods with defined axes of

the femoral neck and diaphysis in 3Dare reproducible and independent of

femur positioning. The current use of 2D methods ignore accepted geo-

metrical rules of measurement in imaging and ignore the errors caused by

femur positioning and a not reproducible definition of the axis of the

femoral neck. Therefore, the results of clinical studies using 2D methods

for the measurement of FNA cannot be compared.

848 Skeletal Radiol (2017) 46:845–871

Correlation between imaging and arthroscopy in patients presenting

with femoroacetabular impingement (FAI) to a young adult hip cen-

ter of excellence

M. Bansal, D. Dalili, N. Khandwalla, M. George, Z. Shah, M. J. Bankes,

A. Isaac;London/UK

Purpose: To compare the imaging findings seen on static, dynamic and

functional studies performed in this cohort of patients, with the intraop-

erative arthroscopic findings.

Methods and Materials: Two radiologists retrospectively reviewed all

imaging performed in 510 patients presenting with FAI between January

2013 and December 2015.

The imaging modalities utilised included plain radiographs, Computed

tomography (CT), Magnetic resonance imaging (MRI), combines single-

photon emission computed tomography/computed tomography imaging

(SPECT CT) and dynamic high resolution ultrasound imaging (US).

The imaging findings were documented in a proforma, which was de-

vised to mirror, the standardised proforma currently used in arthroscopy

in our institution. Both radiologists were blinded to each other’s findings

and/or to the arthroscopy findings.

The findings were then compared those documented on the arthroscopy

proformas using Student t-test analysis. Inter-observer agreement was

assessedwithCohen’s kappa and Spearman's correlation (Rs) coefficients.

Results: There was statistically significant correlation between the arthro-

scopic and imaging findings.

Functional imaging offered good insight into the mechanical causes of

impingement and at times, superior localisation of pain generators.

Dynamic US imaging confirmed the diagnosis of snapping hip conditions

(iliotibial band and/or psoas snapping syndromes), as well as tendonosis.

Subtle intra substance tears were best demonstrated on US. Doppler eval-

uation of the region of interest sometimes confirmed the diagnosis of

active inflammation, in the absence of underlying architectural changes

in the tendons. US also played a crucial role in image-guided therapy.

Conclusion: The current imaging repertoire modalities offers excellent

problem solving tools.

Understanding the diagnostic value of each modality, its relevance and

possible applications in certain cohorts of patients would help both radi-

ologists and surgeons reach an accurate diagnosis and plan tailored pa-

tient centered management plans.

A prospective comparative study between three dimensional

pelvimetry by low-dose stereoradiography versus low-dose helical

CT pelvimetry

A. Podda, P. Padoin, J.-P. Nueffer, Y. Petegnief, E. Delabrousse, S. Aubry;

Besancon/FR

Purpose: To evaluate the reliability of pelvimetry measurements assessed

by stereoradiography imaging (SRI) and to assess maternal and fetal

radiation dose compared to lowdose helical CT (MDCT) pelvimetry.

Methods and Materials: The institutional review board approved this

study, and written informed consent was obtained from thirtyfive preg-

nant women. They were prospectively included and underwent consecu-

tively a synchronous front and lateral lowdose SRI and a lowdose MDCT

of the pelvis. Pelvimetry measurements were anonymously measured on

dedicated SRI software and PACS viewer, and were then compared. Skin

dosimeters were used to evaluate the radiation dose.

Results: SRI-MDCT correlation (Pearson; mean bias) was very good for

the transverse inlet diameter (0.92;0.09cm), the anteroposterior diameter

of pelvic Inlet (0.92; 0.47cm), the maximal transverse diameter (0.9;

0.21cm), and the sacrum length (0.9; 0.09cm). Correlation was good for

the sacrum curvature (0.75; 0.06cm), the Magnin index (0.7; 0.5cm) and

the anteroposterior diameter of pelvic outlet (0.6; 0.52cm). It was low for

the transverse outlet diameter (0.5) and very low for the bispinous diam-

eter (0.22; 0.8cm).

The fetal dose was 13.1 times lower in SRI (87+/26 μGy)thaninCT

(1140+/220μGy, p<0.0001). The effective maternal dose was 3.1 times

lower in SRI (97+/21μSv) than in CT (310+/60μSv, p<0.0001).

Conclusion: Pelvic inlet measurements by SRI are reliable. For each of the

other diameters, measurement bias is low. Compared to CT pelvimetry, SRI

leads to a significant decrease in fetal and maternal radiation dose.

Reliability of the pelvic inlet measurements and lower radiation dose sug-

gests that SRI should be proposed as an alternative to CT pelvimetry.

Iliac Wing Sign: A sentinel sign for ipsilateral pelvic and hip

disorders

A. Marchand, I. Ract, R. Guillin; Rennes/FR

Purpose: On MRI, the “iliac wing sign”(IWS) corresponds to a high

intensity linear image along the iliacus muscle attachment entering the

iliac wing on fat-suppressed T2-weighted spin echo sequences. The aim

of this study was to correlate IWS with pathological and demographic

data of patients and to assess the accuracy of this sign as a sentinel feature

in pathological conditions of the pelvis and hips.

Methods and Materials: The local ethics committee approved this retro-

spective study. Two radiologists interoperatively reviewed the findings of

304 MRI examinations performed between January 2010 and December

2012. IWS presence was recorded and characterized as unilateral (U-IWS),

bilateral symmetrical (B-IWS) or bilateral asymmetrical (BA-IWS).

Demographic data and pathological conditions identified on MR imaging

sequences were also reported.

Results: Overall, 220 MRI examinations (72%) revealed a pathological

condition, with IWS present in 81 cases (27%): 29 U-IWS, 19 B-IWS and

33 BA-IWS. IWS yielded a specificity of 96%, sensitivity of 35%, positive

predictive value (PPV) of 96% and negative predictive value (NPV) of 36%.

Regarding IWS type, the PPV was 100% for U-IWS and BA-IWS.

Patient age was the only demographic data significantly correlated with IWS

(p<0.001). Interreader reliability in IWS detection was excellent (κ=0.983).

Conclusion: IWS is associated with age, particularly when characterized

by a bilateral pattern. In unilateral or bilateral asymmetrical types, the

PPV of 100% shows that IWS is a reliable sentinel sign of disorders in

the ipsilateral pelvic and hip region.

Friday, June 16

Scientific Paper Session - Spine

Enthesopathy of Erector Spinae at the Iliac Crest: A Frequent Cause

for “Nonspecific”Low Back Pain –an Ultrasound Study

P. Todorov; Plovdiv/BG

Purpose: Background: Low back pain is the most frequent musculoskel-

etal complaint, nevertheless, even using the full armamentarium of diag-

nostic tests the exact (or specific) cause for it could be identified in only

Skeletal Radiol (2017) 46:845–871 849

part of the patients. Enthesopathies are the underling lesions in many

MSK diseases and there are numerous entheses in the lower back. In

many LBP patients, there is localized spontaneous and palpatory pain

over the posterior medial iliac crest. This area corresponds to the attach-

ment site (enthesis) of the erector spinae (ES) caudal tendon fibers to the

iliac bone. Musculoskeletal ultrasound is a rapidly developing imaging

modality, particularly efficient in the visualizing of soft tissue structures

like entheses. Interestingly almost all US studies on enthesial pathology

focus on the peripheral entheses.

Aim: By means of MSK US to study and evaluate the caudal entheses of

ES on the posterior medial iliac crest in patients with pain over this area as

well as in subjects without such complaints.

Methods and Materials: 97 patients (65 with unilateral and 32 with

bilateral symptoms), as well as 52 healthy controls of matching sex and

BMI were included in the study. The unaffected pain free side of the

patients with unilateral complaints also served as a control group. Thus,

in total there were 129 symptomatic entheses and 169 (65 contralateral in

patients plus 104 in healthy controls) no symptomatic entheses. All sub-

jects were examined in prone position. Longitudinal and transverse scans

of the attachment sites of the ES muscle to the medial iliac crest were

obtained with linear 12 MHz transducer (Esaote MyLab 40HD). The

following parameters were analyzed: 1. Thickness of the entheses; 2.

Echogenicity, structure and margins of the entheses; 3. Calcifications; 4.

Cortical irregularities of iliac bone. Enthesopathy was defined when ab-

normal US findings were visible in two perpendicular planes.

Results: Painful entheses were thicker than nonpainful ones (Р<0,0001

when comparing both with contralateral and with healthy controls”entheses)

irrespective of age, sex and BMI of subjects. The following sonofeatures

were observed significantly more often in the entheses at the painful site:

diffuse hypo echogenicity (P<0,0001), convex upper margins (P<0,0001),

presence of well-defined hypoechoic areas in the tendon substance -tears?

(P=0,001), calcifications (P=0,019) irrespective of age, sex and BMI.

Conclusion: As in other parts of the body, enthesopathies could be fre-

quent source of pain in the lower back. Clinically relevant enthesopathy

of ES can be diagnosed by a standardized MSUS examination.

Traumatic Thoracic and Lumbar Vertebral Injuries –Current CT

Report Status in a Tertiary Institute

A. A. Al-Taie, A. Y. I. Taha, H. A. Aboughalia, D. Mehrab Khan, D. M.

Baco; Doha/QA

Purpose: This study aims to assess radiologists’CT reports in terms of

descriptive clarity and comprehensives in our institute.

Compared to spine surgeons’perspective represented by the AO spine

thoracolumbar (TL) classification system.

AO TL classification morphological desciption in summary assess frac-

ture involvment of the vertebral body posterior wall, either or both supe-

rior and inferior endplates involvment, extension to the vertebral posterior

element (transosseous, transligamentous or both) and presence of dis-

placement or dislocation.

Methods and Materials: Retrospective non-randomized study.

RIS\PACS system was used to collect sample data of patients with

dorsolumbar vertebral fractures reported in Hamad General Hospital

Doha/Qatar (One of the biggest level 1 trauma center in the middle east)

between May 2011 and May 2015.

We included a total number of 74 patients in our study.

AO TL spine classification morphological description is used as a clinical

verdict for CT scan report assessment.

Images and reports were reviewed separately to illustrate current

reporting status for vertebral fractures.

Further description upon final submission.

Results:

Tota l numbe r of c ases: 74.

Gender: 66 male patients and 8 female patients.

Overall concordance between radiological report and AO TL spine

trauma classification morphological description: Conconrdant in 28

CT scan reports out of the total 74 cases. Discordant in 46 CT scan reports

out of the total 74 cases.

Individual sub-types concordance between radiological report and

AO classification: Type A: Total cases are 64 out of which 22 are

conconrdan t and 42 are discordant. Type B : Total cases are 7 out of which

2 are conconrdant and 3 are discordant. Ty pe C: Total cases are 3 out of

which 1 is conconrdant and 2 are discordant.

Conclusion: A considerable portion of our CT scan reports’displayed

discordance relevant to the AO TL spine classification morphological

description.Thus, an urgent need to restructure our TL injuries CT scan

reports’to address the clinical needs is justified.

We suggest creating a synoptic radiology report based on the AO TL

spine classification.

This will help radiologists build a strong report in-line with the clinical

management plan.

The AO system for TL injuries creates a clear simple way of communi-

cation between the radiologists and the referring physicians.

This classification system lexicon in radiological reporting can unify

terminology used by all members of medical team.

Another benefit is from the academic and research perspective as having a

standardized report will lead to effective, active and unbiased research

input from both radiology and spine surgery sides.

Back and hip pain in elite rowers: A hip injection strategy for pre-

labral capsulitis

B. Sharif

,A.Redgrave

, L. Arnold

,D.Shah

, D. Remedios

;

Harrow/

UK,

Bisham Abbey/UK

Purpose: Back and hip pain are common in elite rowers and traditionally,

a primary lumbar spine aetiology was thought likely. Spinal overuse

injuries are often treated with intervention, possibly surgery and long

periods of rehabilitation, delaying return to competitive sport, and often

limiting athletes' potential. Recent studies have identified that back pain

in elite rowers may be secondary to hip injury, specifically pre-labral

capsulitis resulting from acetabular labral tears, also seen with kicking

sports. The purpose of this study is to show the outcome and value of

injection therapy plus physiotherapy for treating hip capsulitis in elite

rowers presenting with back and hip pain.

Methods and Materials: Over a two year period elite rowers

complaining of recalcitrant, chronic hip and back pain with MRI-

diagnosedlabral tear were referred for intra-articular hip injection therapy

followed by rehabilitation. All underwent hip ultrasound to confirm labral

tear; measurement of the pre-labral capsular thickness; and assessment of

hip flexion, adduction and internal rotation, pre and post injection with

Depo-Medrone (methylprednisolone acetate) 40mg and Bupivacaine

Hydrochloride 0.5% 2mls. Long term outcome was assessed as return

to competitive sport.

Results: Eleven male and thirteen female rowers/scullers with a mean age

of 26 years were referred with hip and low back pain over a two year

period. A total of 35 hips in 24 consecutive athletes were scanned and all

demonstrated evidence of acetabular labral tear and pre-labral capsulitis

with mean capsular thickness of 2.3mm (normally up to 1mm) and 95%

confidence interval (95% CI) of 2.08-2.52. Following injection, the mean

improvement for hip flexion was 22 degrees (95% CI 19.3-24.7), mean

adduction 21.2 degrees (95% CI 18.7-23.7) and mean internal rotation

23.6 degrees (95% CI 20.8-26.4). The majority of injected and

850 Skeletal Radiol (2017) 46:845–871

rehabilitated athletes (22/24, 92%) returned to competition, many going

on to win international medals.

Conclusion: For elite rowers with back and hip pain, pre-labral capsulitis

secondary to acetabular labral tear is often the primary condition with

presumptive compensatory overuse injury of the lumbar spine. The novel

approach of ultrasound-guided injection therapy plus rehabilitation is an

effective treatment for pre-labral capsulitis. This strategy will enable most

athletes to return to sport and to achieve their potential.

Using dedicated low field MRI in ligament lesion of atlantoaxial in-

stability and dysfunction of C0-C2

S. Giannini, M. Pietrangeli, G. Montanari, F. Matera; Rome/IT

Purpose: The purpose of this study is to evaluate suspect lesion of the

atlantoaxial joint ligaments in patients suffering from chronic cervical

pain through a weight bearing MRI.

Methods and Materials: Between December 2015 and January 2016,

we examined 12 patients between 22 and 55 years old: 9 women and 3

men, affected by a suspect instability of the atlantoaxial joint. Patients

denounced dizziness, headache, neck pain and a sense of instability. All

patients were examined through a dedicated low field Esaote G Scan Brio

MRI. In 6 patients, first we used axial 3D-HYCE sequences and T2

coronal ones in clinostatism, and then, the same ones in orthostatism.

Between November 2016 an January 2017, in another 6 patients, we used

first an Isotropic 3D sequences in clinostatism and then in weight bearing

position, with the reconstruction of three planes. The position of the

patient examined in orthostasis included locking the head with a wedge

under the chin. In 5 patients reporting during the anamnesis that they had

problems rotating the head, feeling dizzy, at the end of the exam, we have

carried out a second functional dynamic exam in right and left side bend-

ing, recording a movie.

Results: All examined patients suffered disabling chronic pain from a period

running from one month to one year, often arose after a trauma, mostly

caused by a car or motorbike accident or following a whiplash injury. The

static and dynamic MRI exam showed a metameric misalignment and a

widening of the lateral dental space affected by a lesion of the alar ligament,

a rotation of C2 spinous on the opposite side and dishomogenous signal

intensity with a residual hyperintense area in the T2 weighted sequences in

cases where the trauma was more recent. All cases showed a damage of the

Tillaux triangle of the affected side The orthostatic exam emphasized insta-

bility, but not a specific discomfort for the patient.

Conclusion: The functional exam was able to explain the ligament, rota-

tory and Tillaux triangle damages, showing also a perineural and muscle

fibrosis. The orthostatic exam increased the widening of the side dental

space and emphasized the ligament lesion. The 3D Isotropic sequence

allowed accelerating the acquisition time, reducing the risk of artifacts

caused by involuntary movements.

Reliability and clinical validity of an MRI grading system for cervical

foraminal stenosis

H. J. Park; Seoul/KR

Purpose: Park system is a MRI grading system for cervical neural fo-

raminal stenosis (CNFS) and consists of 4 grades (0-3) based on the

foraminal shape of 45° T2-weighted oblique sagittal images. The objec-

tive of this study was to evaluate the inter-reader reliability of the Park

system among radiologists, residents, and clinicians. This study also

assessed the correlations between radiologic and clinical findings.

Methods and Materials:A total of 289 patients (M:F = 155:134, mean age

of 50 years) who underwent oblique sagittal MRI of the cervical spine at our

hospital were included. According to the MR grading system suggested by

Park et al., two radiologists, two trainees, and two clinicians measured CNFS

grade at the most narrow point. A neurosurgeon assessed the associated

clinical manifestations. Kappa statistics were used to analyze the inter-

reader agreement among the radiologists and clinicians. The clinical corre-

lations between grade and positive clinical manifestations were assessed with

Rs using nonparametric correlation analysis (Spearman’s correlation).

Results: The overall inter-reader agreements between radiologists, between

trainees, between clinicians, and between radiologists and clinicians were

almost perfect (k = 0.80 –0.96). There were moderate correlations between

grade and clinical manifestations in each group (R = 0.562-0.669). There

were moderate to relatively high correlations between grade and neurologic

manifestations based on cervical level (R = 0.570-0.715) (all p-values < 0.05).

Conclusion: Regardless of reader experience, there was substantial to

almost perfect inter-reader reliability with the Park system for CNFS

based on oblique sagittal MRI.

Lee’s grading system for central lumbar spinal stenosis and decision-

making tool for surgical treatment

H. J. Park; Seoul/KR

Purpose: To evaluate the correlation between Lee’s grades which de-

scribed recently and surgical intervention for central lumbar spinal steno-

sis (CLSS) and to assess whether this grading system can be used as a

decision-making tool for the surgical treatment of this condition.

Methods and Materials: This retrospective study included 290 patients

(M:F = 156:134; mean age, 46±16 years). Radiologists assessed the pres-

ence and grade of CLSS at the stenosis point according to Lee’sgrading

system in which CLSS is classified into four grades according to cauda

equina shape. Correlation coefficients (r

) between Lee’s grades and the

operation were calculated with Spearman rank correlation.

Results: In the operated patients, grade 2 was most common (50-58%),

grade 3 was less common (35%), and grade 0 was least common (2-3%).

In the non-operated patients, grade 1 was most common (63-65%), grade

0 was less common (15-16%), and grade 3 was least common (8%). The

distribution of grades differed between the operated and non-operated

groups (p< 0.001). Whereas grades 0 and 1 occurred in less than 25%

of patients who underwent surgery, grades 2 and 3 occurred in more than

88%. A moderate correlation between grade and operation was found (r

= 0.632 and 0.583).

Conclusion: Lee’s grade was moderately correlated with the surgical

intervention. Lee’s grading system can be used as an ancillary method

in decision-making for surgical treatment of CLSS.

Targeted MDCT-guided ganglion impar blockade for coccydynia

D. Amos

,K.Durley

, R. Sidebottom

,J.J.Chen

,J.A.Sutcliffe

,S.

Yanny

,T.Meagher

,R.J.Hughes

, D. McKean

;

Oxford/UK,

Aylesbury/UK,

Perth/AU

Purpose: To describe and evaluate the outcomes for targeted multi-

detector computed tomography (MDCT) guided ganglion impar block-

ade for the treatment of coccydynia.

Skeletal Radiol (2017) 46:845–871 851

Methods and Materials: We performed a retrospective audit of patients

who underwent MDCT-guided ganglion impar blockade injections at our

institution from March 2011 to June 2016. Primary outcome measures

were pain scores at 24 hours and 2 weeks post injection and the incidence

of complications.

Results: From March 2011 to June 2016, 27 MDCT-guided ganglion

impar blockade injections were performed. Complete data was obtained

for 18 patients (13 female, 5 male) who received 22 injections. Technically

successful needle placement was achieved in all cases with accurate needle

placement without immediate complications. Out of 22 injections, 72.7%

(n=16) reported a positive diagnostic response at 24 hours and 95.5%

(n=21) reported a positive therapeutic response at 2 weeks. Mean pain score

pre-injection was 8.4 (range 6 –10), at 24 hours mean pain score was 4.4 (0

–10) and at 2 weeks the mean pain score was 3.6 (range 0 –9). One patient

reported symptoms of temporary urinary retention following the procedure.

No further significant complications were reported.

Conclusion: MDCT guided injection for coccydynia allows for confident

location of the ganglion impar at the caudal end of the sympathetic chain in

the retroperitoneal sacrococcygeal region. We report high rates of therapeu-

tic response to MDCT guided blockade of the ganglion impar which may

be related to the accuracy of needle placement. Our results demonstrate that

MDCT guided ganglion impar is an effective technique to relieve intracta-

ble perineal pain of sympathetic origin in patients with chronic coccydynia.

Iterative reconstructions and tube voltage variation as methods of

radiation dose reduction in CT imaging of spine fractures

M. Brönnimann, C. Jackowski, J. Heverhagen, M. H. Maurer; Berne/CH

Purpose: To assess the possible extent of tube voltage reductions and the

use of iterative reconstruction techniques with the aim to reduce radiation

dose in computed tomography (CT) imaging of the spine.

Methods and Materials: Nine human cadavers were repeatedly examined

with a CT scan of the whole spine with stepwise tube voltage reductions

from 140 kV to 70 kV and a constant tube current of 250 mA. For each

different tube voltage five iterative reconstruction levels (IR 1-5) were

applied. Two blinded readers independently evaluated the CT datasets

starting with the lowest tube voltage category and the highest level of

iterative reconstruction. The tube voltage and the iterative reconstruction

level in which spine factures could be detected were noted. The detected

spine fractures were assigned according to the 3-column model of Davis

into stable and unstable fractures. The highest required level of kV and IR

where both readers detected the different fractures was documented.

Results: In all 9 cadavers, there were 40 fractures, thereof 21 stable and

19 unstable fractures. 39 of all 40 (97,5%) fractures were correctly iden-

tified at 100 kV and the lowest iterative reconstruction level (IR-1). At

extremely low levels of 70 kV and an IR-2 level 55% (22/40) of all and

68% (13/19) of all unstable fractures were seen.

Conclusion: Significant tube voltage reductions in combination with

iterative reconstruction methods still allow a sensitive detection of spine

fractures and might be a possible way to significantly reduce the radiation

dose in CT scans of the spine in clinical practice.

Are whole spine localisers in magnetic resonance imaging examina-

tion of lumbar spine useful for detection of unexpected vertebral

findings? Pilot study

M. Kaniewska, S. E. Anderson, A. Mameghani, F. J. Ahlhelm, R. A.

Kubik-Huch; Baden/CH

Purpose: The main goal of our pilot study was to examine the usefulness

of whole spine localisers/scouts, performed as a part of magnetic reso-

nance (MR) examinations of the lumbar spine by medical technical as-

sistants for exact vertebral localisation, and for detection of unexpected

vertebral findings in thoracic and cervical spine in patients over 65 years.

Methods and Materials: Institutional Review Board approval and in-

formed patient consent was obtained for all patients.

64 MR examinations of the lumbar spine performed at our institution

were retrospectively evaluated. Two patient groups were analysed (group

1: 65 - 80 years of age and group 2: > 80 years). The incidence of detected

vertebral findings (i.e. fractures) in each group was examined.

Sagittal whole spine scouts were used in the assessment of vertebral

findings in lumbar, thoracic and cervical spine.

The coronal whole spine localisers were used for evaluation of additional

findings such as scoliotic spine, malalignment or presence of the ortho-

paedic prostheses.

Exclusions included: presence of spondylodesis/other metal hardware

due to nondiagnostic image quality.

MR main referral reason including lumbar pain was also reviewed.

Results: On sagittal whole spine scout review unexpected fractures were

identified: 4 and 14 fractures in the age group between 65 and 80 years

and above 80 years, respectively

Coronal scout review showed 11 and 12 additional findings (i.e. scoliotic

spine, prosthesis) in age group between 65 and 80 years and above 80

years respectively.

In both groups no pathologic findings of cervical spine were detected. 3

patients were excluded with nondiagnostic/poor image quality.

Referral reasons were lumbar pain 25 of 32 in younger age group (65-80

years age group) and 21 of 32 in older age group (over 80 years age

group). However, in the latter group in the rest 11 of 32 patients no

specific referral causes were given

Conclusion: There is a role for radiologist to review whole spine scouts

that are performed routinely in MRI examination of lumbar spine for exact

vertebral localisation during planning by MRI radiology technicians.

Inclusion of scout findings in the radiology report would seem prudent.

Our pilot study shows that in patients over 65 years of age, whole spine

scout review gives additional information on other spine segments includ-

ing unexpected fracture. These may require further imaging.

Is vertebral bone marrow edema reduction related to clinical symp-

toms improvement in patients with acute vertebral compression frac-

tures? A clinical-radiological study

A. Piazzolla, G. Solarino, D. Bizzoca, F. Dicuonzo, B. Moretti; Bari/IT

Purpose: Vertebral bone marrow edema (VBME) is a marker of acute

vertebral fractures on Magnetic Resonance Imaging (MRI). The evolu-

tion of VBME and its clinical meaning, however, remain unclear. This

prospective observational study aims to assess, in patients with A1 ver-

tebral compression fractures(VCFs) conservatively treated,the evolution

of VBME and any relationship between VBME and clinical symptoms.

Methods and Materials: Between January 2013 and December 2015, 99

patients with 102 acute thoracic or lumbar spinal fractures type A1, ac-

cording to the AOSpine thoracolumbar spine injury classification system,

were selected by our institute.

The patients were divided into 2 groups on the basis of the fracture

aetiology: 34 post-traumatic VCFs were included in group-A, whereas

68 osteoporotic VCFs in group-B. Osteoporosis was documented using

lumbar spine T-score. All the patients were treated with C35 hyperexten-

sion brace for 3 months, bed rest for the first 25 days. Patients with

osteoporotic fractures also received antiresorptive therapy and vitamin

D supplementation.

852 Skeletal Radiol (2017) 46:845–871

At 0, 30, 60, and 90 days, patients underwent MRI evaluationand clinical

evaluation, using the Visual Analogue Scale (VAS) back pain and the

Oswestry Disability Index (ODI).

VBME in the collapsed vertebral body was defined as decreased signal

intensity (SI) on T1-weighted images and increased SI on STIR images.

Using a DICOM software (Weasis Medical Viewer, Atlassian), two re-

gions of interest (ROIs), i.e. the fractured vertebral body and the VBME

zone, were identified manually in STIR sequences, taking care not to

include the cortex. The means of area in mm

of both ROIs and their

ratio, expressed in percentage, on three sagittal MRI slices, performed

along the left pedicle, the spinous process, and the right pedicle, were

calculated.

The paired t test, the unpaired t test and the Pearson correlation test were

performed. The tests were 2-tailed with a confidence level of 5%.

Results: A significant VBME mean area, VAS, and ODI scores reduction

was recorded at 60 and 90-days follow-ups versus baseline. A significant-

ly faster VBME reduction in traumatic VCFs (group-A) compared with

osteoporotic VCFs (group-B); this quicker VBME reduction in group-A

correlates with a faster clinical improvement. A positive correlation be-

tween VBME reduction and VAS and ODI scores improvement was

found in both traumatic and osteoporotic VCFs.

Conclusion: In acute VCFs conservatively managed, VBME slowly de-

creases in the first 3 months of MRI follow-up. This VBME reduction is

related to clinical symptoms improvement.

Is it really sacroiliitis? Radiological and clinical follow up of subtle

sacroiliac joint magnetic resonance imaging findings in patients with

suspected axial spondyloarthritis

H. H. C. Lee, B. Lopez, L. Meacock, J. Galloway, D. Elias; London/UK

Purpose: Magnetic Resonance Imaging (MRI) of the sacroiliac joints is

central to the diagnosis of axial spondyloarthritis (SpA) according to

Assessment in Spondyloarthritis International Society (ASAS) criteria.

ASAS defines MRI criteria for the diagnosis of sacroiliitis. In our insti-

tution, where subtle or equivocal sacroiliac MRI findings are identified,

which do not reach clear positivity on ASAS criteria, one year follow up

MRI is recommended should symptoms persist. The purpose of our study

was to assess the clinical and MRI outcome of this group of patients at

follow up.

Methods and Materials: All MRI of the sacroiliac joints requested over

a 5 year period for suspected SpA at our institution was retrospectively

reviewed. Patents with subtle sacroiliac changes described in the MRI

report, negative or equivocal on ASAS criteria were included. These

included patients with bone marrow oedema identifiable on a single slice

only; erosions, sclerosis, synovitis or enthesitis without clear marrow

oedema; or marrow oedema atypically located. Follow up MRI was

reviewed in each case to identify any progression of lesions and clinical

records were retrieved to determine whether a diagnosis of SpA was

subsequently made and if any treatment was given.

Results: A total of 607 sacroiliac MR studies were found, 95% referred

from rheumatology and 66 MRI reports described equivocal sacroiliac

changes. Amongst these, a repeat MRI at 12 months was recommended in

44 (66.7%), and repeat MRI was performed in 37 (56.1%) patients (mean

interval to follow up MRI 19.3 months; range 6-46 months). Only 5

(7.6%) had definite sacroiliitis reported on repeat MRI.

Of the 66 patients with initially equivocal MRI findings, 36 (54.5%) were

regarded as mechanical pain and were subsequently discharged. 20

(30.3%) were eventually given a diagnosis of SpA, 7 (10.6%) were given

a diagnosis of rheumatoid arthritis or lupus and 3 were lost to follow up.

Conclusion: In our retrospective study of patients with clinically

suspected SpA and equivocal sacroiliac MRI findings, follow up MRI

showed active sacroiliitis in very few patients, even though 30% were

diagnosed with SpA based on their clinical symptoms. This casts doubt

on the value of follow up MRI in such cases. A data-driven definition of

early SpA on MRI is required to establish an appropriate approach when

these subtle changes are encountered.

Lumbar and sacral plexuses anatomy: Magnetic resonance evalua-

tion with 3D isotropic T1-weighted sequence

G. Lefebvre, J. Hanckowiak, M. El Rafei, V. Morel, X. Demondion, A.

Cotten; Lille/FR

Purpose: To evaluate the detection of the main nerves of the lumbosacral

plexus and their anatomical variations using 3D-TSE T1w MR sequence.

Methods and Materials: We retrospectively reviewed the studies of the

pelvis that included 3D isotropic (reconstructed voxel:

0.43x0.43x0.48mm) TSE T1-weighted sequence (TR/TE: 350/20.5ms)

performed on a 3T system between January 2016 and December 2016.

Exclusions were related to artifacts, unadapted FOV for plexus coverage

and patients referred for nerve exploration or with pathological nerve

findings. Visualization of 11 collateral and terminal nerve branches of

lumbar (ilioinguinal, iliohypogastric, genitofemoral, femoral, lateral fem-

oral cutaneous, obturator nerves) and sacral (gluteal superior, pudendal,

posterior femoral cutaneous, sciatic nerves and lumbosacral trunk) plex-

uses on each side were recorded by two radiologists in consensus.

Selected anatomical landmarks and variants for each nerve branches were

also analyzed.

Results: 25MR examinations were excluded. 30 patients (14 females and

16 males, mean age: 49 +/- 18 years) were included (60 lumbar and sacral

plexuses). Genitofemoral, Ilioinguinal and iliohypogastric nerves were de-

tected in respectively 8 (13.3%), 0 (0%) and 14 cases (23.3%). Posterior

femoral cutaneous nerve was differentiated from the sciatic nerve in 58

cases (96.7%). Lateral femoral cutaneous nerve was seen in 48 cases

(80%). Femoral, obturator, superior gluteal, sciatic and pudendal nerves

and lumbosacral trunk were seen in all cases (100%). Proximal variations

of femoral nerves included posterior course to psoas muscle (17 cases,

28.3%) and course through the iliac belly (3 cases; 5%). Early division of

obturator nerves, proximal to obturator foramen was found in 7 cases

(11.7%). Lumbosacral trunk variations included separated courses of L4

and L5 up to the sciatic nerve (5 cases; 8.3%) and no contribution of L4 root

(4 cases; 6.7%). Sciatic nerve course related to piriformis muscle (Anson

and Beaton classification) was classified as type 1 (56 cases; 93.3%) and

type 2 (4 cases; 6.7%). Superior gluteal nerve demonstrated afferences from

lumbosacral trunk in all cases and from S1 in 36 cases (60%).

Conclusion: 3D-TSE T1w MR sequence allows visualization of most of

plexus branches and provides information on their frequent anatomical

variants.

“Vanishing gas”phenomenon as an early predictor of spondylodiscitis

detected with CT

D. Harder, M. Garcia Alzamora; Basel/CH

Purpose: Elderly patients with an infection of unknown origin frequently

get referred for chest/abdomen/pelvis CT for the search of the cause of

infection, as their symptoms are in many cases quite unspecific. Amongst

the different symptoms, pain of the cervical, thoracic or lumbar spine is

often reported and therefore is diagnostically not further indicative.

Skeletal Radiol (2017) 46:845–871 853

The purpose was to analyze the significance of the “vanishing gas”phe-

nomenon for the detection of early spondylodiscitis by CT.

Methods and Materials: CT- and MRI data of 15 elderly patients (> 60

years) with histologically proven lumbar or thoracic spondylodiscitis

were retrospectively analyzed for the presence of spinal osteochondroses

and vacuum disc phenomena. The CT and MRI at the time point of the

spondylodiscitis (same day or a few days before) were compared with a

previous CT examination (performed for another reason prior to

spondylodiscitis) for the presence of spinal degeneration and a vacuum

phenomenon at the segment of the later infection.

Results: In 15 patients with histologically proven spondylodiscitis the

MRI at the time point of the spondylodiscitis showed typical features of

osteomyelitis/discitis without the presence ofgas in the corresponding CT

in the affected segment. However, in all 15 cases a CT performed at a

prior time point (prior to spondylodiscitis) showed the presence of gas in

the same segment hereby disclosing a “vanishing gas”phenomenon dur-

ing the development of an infection

Conclusion: Especially in elderly patients with an infection of unknown

origin or unspecific back pain, who obtain a CT for primary diagnosis, the

comparison of endplate degeneration with prior CT examinations can

detect early spondylodiscitis. Hereby the determining imaging sign on

CT is the lack of gas in the affected intervertebral disc at the time point

of the infection - compared to the prior CT scan showing gas in the same

segment.

Friday, June 16

Scientific Paper Session - Metabolic and other

The influence of vertebral fractures (VF) and vertebral osteoarthrosis

(VO) on Trabecular Bone Score (TBS): Preliminary results

A. Poloni

,C.Messina

,C.G.Monaco

, D. Albano

,M.Galia

,L.M.

Sconfienza

;

Arcene/IT,

Milan/IT,

San Donato Milanese/IT,

Palermo/IT

Purpose: TBS is a textural score that provides an indirect index of tra-

becular microarchitecture from lumbar spine (LS) dual energy x-ray ab-

sorptiometry (DXA). We evaluated the effect of VO and VF on bone

mineral density (BMD) and TBS.

Methods and Materials: We retrospectively identified all patients that

performed a LS DXA in January-March 2015 together with a LS x-ray/

MRI (maximum interval with DXA=6 months). Among them, we includ-

ed patients with VO or VF diagnosed on LS x-ray/MRI with a maximum

of two vertebrae involved. We calculated the BMD/TBS difference be-

tween vertebrae affected by VO/VF and the adjacent vertebrae with the

greater values of BMD/TBS; and between vertebrae affected by VO/VF

and the average L1-L4 BMD/TBS (average value included the vertebrae

with VO/VF).

Results: Out of 258, we included 20 patients (19 females, age=72±10y)

with VO (n=13) or VF (n=7). Mean BMD (g/cm

): vertebrae with VO/

VF=1.004±0.167; adjacent-vertebrae=0.935±0.154; L1-L4=0.946

±0.127. Mean TBS: vertebrae with VO/VF=1.300±0.122; adjacent-ver-

tebrae=1.252±0.122; L1-L4=1.261±0.091. Considering VO+VF togeth-

er, all differences were significant (p<0.05), except for BMD difference

between vertebrae with VO/VF and adjacent-vertebrae (p=0.082).

Considering only VO vertebrae, all differences between vertebrae were

significant (p<0.05). Considering only VF vertebrae, no differences were

found with adjacent-vertebrae/L1-L4 for BMD and TBS (p>0.119).

Correlations between BMD and TBS for vertebrae with VO/VF were

all significant (p<0.05): R=0.5247 (VO+VF), R=0.6194 (only VO),

R=0.9224 (only VF).

Conclusion: Compared to adjacent-vertebrae and L1-L4, VO significant-

ly impacts both on BMD and TBS, while no differences were found for

VF. BMD and TBS are positively correlated, especially for VF.

The impact of image analysis errors (IAE) on lumbar spine (LS) and

proximal femoral (PF) dual energy x-ray absorptiometry (DXA)

C. G. Monaco

, A. Poloni

, V. Buscarino

,V.Chianca

, C. Messina

,L.

M. Sconfienza

;

San Donato Milanese/IT,

Arcene/IT,

Milan/IT,

Naples/IT

Purpose: IAE in LS and PF DXA are common. We evaluated the effect

of IAE on bone mineral density (BMD) and T-score.

Methods and Materials: DXA images of patients who performed a LS/

PF DXA in January-March 2015 were retrospectively reviewed and

checked for IAE. When a IAE was present, an expert radiologist made

necessary corrections. For LS-DXA we considered the average L1-L4

BMD and T-score. For PF-DXA we considered the total hip (TH) and

neck values of BMD.

Results: We evaluated n=131 LS-DXA and n=142 PF-DXA in 150 pa-

tients. We found IAE in n=79 LS-DXA (60.3%) and n=93 PF-DXA

(65.5%). Most frequent IEA for LS-DXAwere inaccuracies in vertebral

inclusion/exclusion (40/79; 50.6%) and intervertebral lines placement

(ILP) (37/79; 46.8%). Most frequent IEA for PF-DXA were incorrect

neck-box areas (NBA) and total-box area (TBA), 36/93 (38.7%) and

33/93 (35.4%) respectively. After re-analysis, mean L1-L4 BMD: base-

line=0.885±0.165, corrected=0.863±0.162 (variation=2.6%); mean NBA

BMD: baseline=0.658±0.104, corrected=0.659±0.108 (variation=-

0.2%); mean TBA BMD: baseline=0.766±0.113, corrected=0.764

±0.112 (variation=0.3%). Differences between LS-DXA BMD and T-

score pre- and post-correction were statistically significant (p<0.01) when

considering all errors as well as inaccuracies in vertebral inclusion/

exclusion alone. For errors in ILP, differences were significant only for

BMD values (p<0.05). No significant difference was found between

baseline and corrected PF-DXA in terms of BMD and T-score, consider-

ing all errors, incorrect NBA and incorrect TBA.

Conclusion: IAE significantly impacts only on LS-DXA and not on PF-

DXA. IAE should be avoided for a proper diagnosis and therapy.

Trabecular Bone Score and Bone Mineral Density: Are They

Influenced by Body Mass Index?

M. Petrini

, C. Messina

, A. Poloni

, M. Catapano

, F. Sardanelli

,L.M.

Sconfienza

;

Rottofreno/IT,

Milan/IT,

Arcene/IT,

Ottaviano/IT

Purpose: TBS is a textural score that provides an indirect index of tra-

becular microarchitecture from lumbar spine (LS) dual energy x-ray ab-

sorptiometry (DXA). According to proponents, TBS is adjusted to pa-

tient’s body mass index (BMI). In obese patient, due tonoise-related

superimposed soft tissue, bone mineral density (BMD) is usually in-

creased. Our aim was to investigate the effect of BMI on BMD and TBS.

Methods and Materials: We retrospectively reviewed the last 197 DXA

examinations performed at our institution. For each patient we acquired

data on BMD and TBS with DXA and we measured BMI. An experi-

enced reader evaluated all examinations. TBS and BMD were automati-

cally averaged from L1 to L4 and we categorized T-score according to the

WHO criteria. The presence of osteoarthrosis, in agreement to the

International Society for Clinical Densitometry guidelines, was

854 Skeletal Radiol (2017) 46:845–871

determined when a difference of more than a 1.0 T-score was found

between two adjacent vertebrae. Correlation was estimated using the

Pearson coefficient and multivariate regression using TBS as dependent

variable. Data were presented as mean±standard deviation.

Results: We categorized, based on T score, 54(27.4%) patients with nor-

mal value, 95 (48.2%) with osteopenia and 48(24.4%) with osteoporosis

Overall, BMD was 0.877±0.153 g/cm2, TBS was 1.224±0.117 mm-1 and

BMI was 26±5 kg/m2;;. Osteoarthrosis was evident in 55 (28%) patients.

The correlation between TBS and BMD was: r=0.313 (P<.001), overall;

r=0.431 (P=.040), in patients with BMI≥30 kg/m2; r=0.408 (P<.001), in

patients with BMI<30 kg/m2. We demonstrated a significant bivariate

correlation between TBS and BMI (r= -0.396, P<.001); In patients with

BMI≥30 kg/m2 this correlation was higher (r= -0.501, P=.015) than in

those with BMI<30 kg/m2 (r= -0.207, P=.006). With multivariate regres-

sion analysis we confirmed that BMI and BMD are independently asso-

ciated, overall and in patients with osteoarthrosis, to TBS (P<.001).

Conclusion: BMD and BMI were independent predictors of TBS. There

is a negative correlation between BMI and TBS. TBS evaluation may be

impaired in patients with high BMI.

Reproducibility of bone mineral density and trabecular bone score

with different scan modes on phantom: the effect of a fictitious soft

tissue increase

C. Messina

,A.Poloni

,V.Chianca

, M. Moscatelli

,C.Faletti

,L.M.

Sconfienza

;

Milan/IT,

Arcene/IT,

Naples/IT,

Turin /I T

Purpose: Trabecular Bone Score (TBS) is a textural score that provides

an indirect index of trabecular microarchitecture from lumbar spine (LS)

dual energy x-ray absorptiometry (DXA). TBS mean values have been

reported to be negatively influenced by body mass index (BMI), due to

the increased thickness of superimposed soft tissue. In this phantom study

we evaluated the effect of a fictitious increase of soft tissue thickness on

TBS and bone mineral density (BMD) reproducibility (REP).

Methods and Materials: An Hologic spine phantom was scanned with a

QDR-Discovery W Hologic densitometer. Fresh pork rind layers of

0.5 cm were used to simulate the in-vivo soft tissues. For each scan mode

[fast array (FA), array, high definition (HD)] 25 scans were consecutively

performed, without phantom repositioning, at 0 (no layers), 1cm and 3cm

of thickness. The coefficient of variation (CoV) was calculated as theratio

between standard deviation and mean; percent least significant change

(LSC%) as 2.77×CoV; REP as the complement to 100%of LSC%. BMD

unit: g/cm2, TBS is unitless. Data are provided as mean ± standard

deviation.

Results: REP at 0cm: 99.0%-99.4% (BMD), 98.2%-98.8% (TBS). REP

at 3-cm: 98.7%-98.9% (BMD), 97.4-98.2% (TBS). The difference in

terms of REP decrease between BMD and TBS was comparable at 0

and 3 cm of soft-tissue thickness (-0.8 at 0 cm, -0.7 at 3 cm). Both

BMD and TBS significantly decreased with increasing soft tissue, but

the reduction was more pronounced for TBS. The greatest difference

for BMD and TBS was found at FA: BMD = 0.987±0.010 (0cm) –

0.980±0,013 (3cm), difference of -0,007 (-0.67%, p<0.001); TBS =

1.420±0.026 (0cm) –1.337±0.024 (3cm), difference of -0.083 (-6.17%,

p<0.001). BMD mean differences between 0-3 cm were always lower

than BMD LSC, while TBS mean differences were always higher than

TBS LSC.

Conclusion: TBS REP was overall lower compared to BMD REP. There

was a comparable decrease between BMD REP and TBS REP whit

increasing soft-tissue layers. Both BMD and TBS are negatively influ-

enced by increased soft tissue thickness, but only TBS variations

exceeded the LSC. Thus, for an identical bone quality, TBS may be lower

in patients with high BMI.

Improving the opportunistic identification of osteoporotic vertebral

fractures with Computed Tomography

E. Kariki, P. Bromiley, T. Cootes, J. Adams; Manchester/UK

Purpose: Osteoporotic vertebral fractures (VFs) are the most common

insufficiency fractures. They occur in younger age compared to hip and

wrist fractures, significantly increase morbidity and mortality, and re-

duced life quality. They are strong predictors of future fractures (x5 VF,

x2 hip) and can be diagnosed on all imaging examinations that depict the

spine. Midline sagittal reformatted Computed Tomography (SRCT) per-

formed for unrelated clinical indications is the most sensitive method for

opportunistic identification of VFs. However, evidence consistently

shows they are underdiagnosed on CT, primarily because VFs are poorly

diagnosedon axial images. To improve our diagnostic outcomes, we have

implemented a protocol in which SRCTare routinely performed at time of

image acquisition. We have also developed aVert, a computer-aided di-

agnostic (CAD) tool for the identification of VFs on various imaging

modalities. We reviewed the effect of implementing the new protocol,

and studied how aVert can influence our performance.

Methods and Materials: We retrospectively reviewed the sagittal and

coronal reformatted images of 1000 thoracic and abdominal CTs of pa-

tients over 50 years. Vertebrae were classified as normal, deformed or

fractured, with fractures graded based on the Genant et al semiquantita-

tive method. The original reports were reviewed for reported VFs, the

terminology used and the level of expertise of the reporting physician.

Results: 1000 CT scans were reviewed (female: male = 46:54; median

age 74y females, 69y males). Osteoporotic vertebral fractures were pres-

ent in 260 (26%) scans of which 94 (36%) were reported. The term

“fracture”was explicitly used only in 30 (32% of reports, 12% of all

exams with VFs). In 166 patients (64%) VFs were not reported. The

seniority of the reporter did not influence reporting accuracy.

Application of aVert on the SRCT images demonstrated 90% positive

predictive value and 72% sensitivity.

Conclusion: Routine sagittal CT image reformation improved our VFs

reporting rates by a factor of 3, but two in three exams with VFs were still

missed. With over half million thoracic and abdominal CTs performed

annually in the NHS (2015), these rates are disappointing and unsatisfac-

tory. All moderate and severe VFs were obvious on SRCT images, im-

plying that these were not scrutinised at the time of reporting. Education

of our radiology colleagues on the importance of vigilant review of SRCT

images and reporting of VFs is helpful. Our CAD tool significantly in-

creased our VFs reporting rates and added additional benefit to our VFs

diagnostic performance.

Acknowledgements: Funding Health Innovation Challenge Fund (HICF-

R7-414:Wellcome/DoH).

Ultrasonography and dual-energy CT (DECT) do not provide the

same quantification of urate deposition in gout: results from a

cross-sectional study

T. Pa s c art , N. Namane, A. Grandjean, L. Norberciak, V. Ducoulombier,

J.-F. Budzik; Lille/FR

Purpose: Gout is due to monosodium urate (MSU) deposition in joints

and soft tissues. Ultrasonography (US) and dual-energy CT

(DECT) have been shown to be effective in detecting MSU de-

posits. Both techniques can examine tophi size. DECT is effective

to identify soft-tissue MSU deposits and US can show joint de-

position with the double contour (DC) sign.

Skeletal Radiol (2017) 46:845–871 855

The main objective of this study is to compare the tophus size measured

by US and by DECT. The secondary objective is to evaluate the correla-

tion between the prevalence of the US DC sign and the global volume of

urate deposits measured by DECT.

Methods and Materials: This prospective cross-sectional study included

patients fulfilling the 2015 ACR/EUALR criteria for gout. Patients

underwent US and DECT examinations of their knees and feet. The

largest US tophi was selected as the index tophus. US examination of

the DC sign was performed on the femoro-patellar joints, talo-crural

joints and 1st metatarsophalangeal joints. Total volume of urate deposits

of knees and feet was measured by DECT. The primary endpoint was the

intra-class correlation coefficient (ICC) of the volume of the index tophus

measured by US and DECT [CI 95%].

Results: A total of 64 patients were included in the study, of which 35

patients presented with at least one US tophus. Patients were in

average 64.5±16.3 years old, 84.4% were male, had an average

ACR/EULAR score of 13.6±2.5, and disease duration was 12

±14.7 years. Of the tophi identified with both techniques, 21 were

localized in the feet and 8 in the knees. The ICC of the tophus

volume assessment by US and DECT was 0.45 [0.12-0.69]. The

average volume of the largest US tophi was 2.7±6.5 cm3 and 1.5

±3.3 cm3 when measured by DECT. If the index tophus was

localized in the knee, the ICC was 0.36 [0-0.82] and was

0.68[0.37-0.86] if the tophus was in the foot. The Spearman cor-

relation coefficient between the DECT urate volume and the num-

ber of joints with a positive DC sign was 0.15.

Conclusion: US and DECT do not provide the same assessment of to-

phus size. The correlation is improved when considering tophi localized

in the feet. The number of joints with positive DC sign does not correlate

to the volume of urate deposition in the soft tissues measured by DECT.

Validation of asynchronous quantitative bone densitometry of the

spine: Accuracy, short-term reproducibility, and a comparison with

conventional quantitative computed tomography

L. Wang, L. Xu, X. Cheng, Y. Su; Beijing/CN

Purpose: Asynchronous calibration quantitative computed tomography

(QCT) is a promising new technology for opportunistic screening for

osteoporosis; however, few studies have compared conventional QCT

and asynchronous QCT. Moreover, asynchronous QCT has not yet been

fully validated for the clinical measurement of BMD.

Methods and Materials: we provide a validation of asynchronous QCT

using the European spine phantom(ESP), which is a recognized standard

evaluation tool for bone densitometry, and data from 50 retrospectively

enrolled patients with low-to-normal bone mass. We used the ESP with

repositioning during scanning and assessed the accuracy and short-term

reproducibility of asynchronous QCT. Intra-scanner and intra-observer

precision were each calculated as the root mean square of the standard

deviation (RMSSD) and the coefficient of variation (CV-RMSSD). We

also compared asynchronous and conventional QCT results in 50 clinical

subjects.

Results: The accuracy of asynchronous QCT for three ESP vertebrae

ranged from 1.4–6.7%, whereas intra-scanner precision for these verte-

brae ranged from 0.53–0.91 mg/cc. For intra-observer variability, overall

precision error was smaller than 3%. In clinical subjects there was excel-

lent agreement between the two calibration methods with correlation

coefficients ranging from 0.979–0.988. A Bland–Altman analysis dem-

onstrated that methodological differences depended on the magnitude of

the BMD variable.

Conclusion: Our findings indicate that the asynchronous QCT has good

accuracy and precision for assessing trabecular BMD in the spine.

New dietary strategies addressing the specific needs of elderly popu-

lation for a healthy aging in Europe (NU-AGE): the effect of a tai-

lored Mediterranean diet on body composition

A. Bazzocchi

, A. Santoro

, D. Mercatelli

, F. Ponti

, D. Diano

, G.

Zanirato Rambaldi

,M.Scurti

,A.Berendsen

, B. Pietruszka

,A.

Jennings

N. Meunier

,M.AparisiGomez

, E. Caumon

,S.

Fairweather-Tait

, A. Bialecka

,C.P.G.M.deGroot

,G.Guglielmi

,C.

Franceschi

,G.Battista

;

Bologna/IT,

Wageningen/NL,

Warsaw/PL,

Clermont-Ferrand/FR,

Norwich/UK,

Valencia/ES,

Foggia/IT

Purpose: The proportion of people over 65 years in Europe is predicted to

increase from 18.9% to 28.1% by 2050, with the subsequent increase in

population with age-related diseases and important implications in terms of

healthcare and social costs. It is therefore important to identify health im-

provement strategies for healthy ageing of European citizens. Pre-frail sub-

jects represent 42.3% of the elderly population, a hot target for intervention.

NU-AGE is a large multidisciplinary consortium (30 partners, from 16 EU

countries) aiming at studying the effects of a 1-year elderly-tailored whole

diet intervention on several aging-related variables. The purpose of this

work is to report the impact of the NU-AGE diet approach on body weight

and composition measured by dual-energy X-ray absorptiometry (DXA).

Methods and Materials: A total of 1246 sex-balanced free living elderly

people, ranging from 65 to 79 years and free of major overt diseases, were

enrolled in 5 European countries (Italy, France, United Kingdom,

Netherlands, and Poland) in a 1-year randomized, single-blind, controlled

trial with two parallel arms (control vs. “interventional" diet). Pre-frail

subjects were included as defined by the 5 frailty criteria proposed by

Fried et al. in 2001. Participants followed a diet regimen based on a mod-

ified Mediterranean diet, and underwent whole-body DXA scan to assess

body composition (BC) before (T0) and one year after (T1) recruitment.

Results: DXA was performed in 1139 patients. Preliminary analyses on

BC considered the whole dataset sorted by intervention arm, and inter-

vention arm and country. No significant body weight change was ob-

served in both control and intervention arm, globally. However, a signif-

icant decrease of body weight and body mass index (BMI) (p=0.0201 and

p=0.0488 respectively) was observed in the interventional arm of the

Italian cohort (weight 74.1±12.5Kg at T0, 72.7±11.7Kg at T1). A signif-

icant decrease of total and android Fat-Mass/Lean-Mass (FM/LM) ratio

was achieved in the interventional group only, in the whole cohort (-

0.004/p=0.0192 and -0.005/p=0.0023, respectively), with a more pro-

nounced drop in the Italian population (-0.021/p=0.0001 and -0.039/

p<0.0001). The Skeletal Muscle Index (SMI) changed significantly in

Italian population (+0.001/p=0.0103) after intervention. Total and an-

droid FM/LM and SMI (but not weight/BMI) showed a significant

change with the improvement of patients’frailty status.

Conclusion: NU-AGE diet improves the body composition profile of

elderly people, improving frailty status too. Response to treatment at

one year showed interesting differences among countries. The evaluation

of BC by DXA may deepen insight into the comprehension of nutritional

impact, and disease risk profile.

Radiocarpal plicae: prevalence, MR arthrographic features and as-

sociation with radial-sided wrist pain

A. Monier, P. Omoumi, M. D. S. Durand, J. P. Puyal, F. Tobalem, C.

Bollmann, F. Becce; Lausanne/CH

Purpose: While plicae, also known as synovial fringes or folds, are well-

recognized anatomic variants of the knee, elbow, and hip joints, their

856 Skeletal Radiol (2017) 46:845–871

occurrence and clinical relevance in the wrist is currently not known. The

objectiveof this study was to assess the prevalence and MR arthrographic

features of radiocarpal plicae, and evaluate their association with radial-

sided wrist pain.

Methods and Materials: We retrospectively reviewed 616 consecutive

wrist MR arthrographies performed over a 10-year period. After exclud-

ing patients with previous wrist surgery or insufficient image quality

(artifacts, no 3D submillimetric isotropic images), two radiologists inde-

pendently assessed 407 MR arthrograms (244 men, mean age 37 years)

for the presence of radiocarpal plicae and associated radioscaphoid carti-

lage lesions. The anatomic and signal intensity characteristics of the pli-

cae (origin, orientation, maximum length, thickness, and cross-sectional

area, as well as subjective thickening) were evaluated. The patients’med-

ical records were reviewed for causes of radial-sided wrist pain and sur-

gical correlations. Radiologic-anatomic correlation was further performed

on 10 formalin-fixed cadaveric wrists.

Results: The prevalence of radiocarpal plicae on wrist MR arthrography

and cadavers was 32% (142/407) and 30% (3/10), respectively.

Interobserver agreement was substantial (weighted kappa=0.79).

Surgical confirmation was available for 4 patients. The mean length,

thickness, and cross-sectional area of plicae were 5.3 ± 1.3 mm, 0.73 ±

0.14 mm, and 4.1 ± 2.2 mm

, respectively. Plicae most commonly orig-

inated from the dorsal aspect ofthe radiocarpal joint, and were proximally

and inferiorly oriented. 9% (13/142) of plicae were associated with

radioscaphoid cartilage lesions. The prevalence of plicae in patients with

radial-sided wrist pain (27%, 47/173) vs. those with other symptoms

(41%, 95/234) was statistically comparable (p=0.81).

Conclusion: Radiocarpal plicae are common anatomic variants seen on

wrist MR arthrography. They are rarely associated with radioscaphoid

cartilage lesions and may be found with or without association with

radial-sided wrist pain.

Ultrasound superb microvascular imaging in the evaluation of syno-

vial vascularity: a preliminary study

S. Gitto

, D. Orlandi

,A.Corazza

,E.Silvestri

,M.A.Cimmino

,L.M.

Sconfienza

;

Milan/IT,

Genoa/IT

Purpose: Superb microvascular imaging (SMI) is an advanced flow-

detection ultrasound (US)-based modality able to detect very

low-flow vessels with high detail and definition. Our aim was

to evaluate the use of SMI in patients with early rheumatoid arthritis

(RA) and RA under treatment with rituximab also comparing the diag-

nostic performance of SMI with that of power Doppler (PDI) and B-mode

US.

Methods and Materials: 30 patients (18 women, mean age 45 ± 11

years) affected by RA with remission-to-moderate disease activity were

examined. Ulnar recess, metacarpophalangeal I-to-V and proximal inter-

phalangeal II-to-V joints of both hands were evaluated using a high-end

US system equipped with a 7-18 MHz broadband linear-array transducer,

PDI and SMI module. From each US examination, short video clips

showing B-mode US, PDI and SMI of synovial vascularity were regis-

tered and exported for image analysis. Two radiologists reviewed video

clips registered for all patients evaluating synovial vascularity intensity

with a semi-quantitative scoring system.

Results: SMI demonstrated the presence of synovial vessel signals in a

significantly higher number of patients than PDI (P = 0.02). Interobserver

agreement for B-mode US, PDI and SMI semiquantitative scoring was

moderate (k = 0.59), almost perfect (k = 0.87) and almost perfect (k =

0.82), respectively.

Conclusion: SMI detects more vessels than B-mode US and PDI in

assessingsynovial abnormalities in RA patients. This may allow for early

diagnosis of synovial inflammation as well as monitoring its dynamic

changes under therapy.

Great exSPECT-CTations: Hybrid imaging in traumatic wrist

injuries

D. Dalili, H. Ilyas, K. Adamson, F. Ul-Hassan, A. Eccles, A. Isaac;

London/UK

Purpose: To establish the added value of SPECT/CT in wrist trauma.

Reflecting on a decade of practice, we compare and correlate the signif-

icance of SPECT/CT with routine crosssectional, sonographic and con-

ventional radiographic imaging.

Methods and Materials: We analysed consecutive SPECT/CT wrist

studies performed in cases with a documented history of trauma between

September 2007 and January 2017.

A 16-slice Philips Precedence® SPECT/CT camera and local protocol

Technetium 99m doses were utilised. In addition, dose adjusted CT ac-

quisition allowed us to produce diagnostic studies in line with ALARP (as

low as reasonably practicable) principles. Blood pool, delayed static and

SPECT/CTof the wrists with whole body planar imaging were acquired.

SPECT/CT results were obtained using a departmental database and cor-

related with electronic patient records. Data collected included demo-

graphics, indications for imaging, previous interventions and imaging,

dose saving results and the referral pathway.

Studies were dual reported by specialist Nuclear Medicine and

Musculoskeletal consultant radiologists.

Findingswere then correlated with recorded clinical outcomes; consisting

of up to 10 years follow up.

Results: Of 333 consecutive SPECT/CT studies performed, 71 studies

followed a clear history of trauma.

Hand/wrist specialists madeall referrals: Orthopaedic or plastic surgeons.

The mechanism of injuries included: road traffic accidents, fall onto

outstretched hand, hyperextension, overuse injuries related to specific

sports (golf wrists, martial arts, tennis), de-gloving injuries.

Indications included: claustrophobia (precluding MRI imaging), occult

fractures, partial union, non-union, osteonecrosis, mechanical response,

loosening (periprosthetic), bone cysts, secondary arthropathy, complex

regional pain syndrome, capsular injuries and periosteal avulsions,

TFCC injuries, biomechanical stress around a prosthesis, bossing and

abutment secondary to acquired positive ulnar variance, calcific

periarthritis, VISI/DISI, post operative surgical bed uptake or metaboli-

cally active healed fractures..

Incidental findings on whole body images included: rib fractures, femoral

bony contusions, old scaphoid fractures, osteoarthritis in neighbouring or

distant joints, clavicle fractures, shin-splint syndrome, sternoclavicular

dislocation, unexpected avulsions or over-use injuries.

Conclusion: Hybrid SPECT/CTis an excellent problem-solving tool best

used as an adjunct to conventional imaging modalities, offering supple-

mentary diagnostic value. It has a role in traumatic injuries, specifically in

complex joints such as the wrist, where physiological information and

anatomical detail allow a better understanding of the causes of patients’

pain.

Interosseous membrane imaging in traumatic forearm injuries

A. Rudel, O. Andreani, C.-P. Raffaelli, H. Barret, B. Moreau, M.-E.

Amoretti, N. Amoretti; Nice/FR

Skeletal Radiol (2017) 46:845–871 857

Purpose: Purpose Knowing the biomechanic features and three locks

concept of forearm Understanding forearm interosseous membrane anat-

omy Being able to diagnose lesions of the interosseous membrane by

radiological means Knowing the involvement of lesions of the

interosseous membrane in the surgical treatmentUpload file (PNG, JPG

or GIF)

Methods and Materials: A group of 14 patients have been studied here.

While retaining the forearm biomechanical concept as well as the anato-

my of the interosseous membrane, radiological explorations both at the

time of the trauma and a few months after were performed on each one of

them. These have been conducted at the request of orthopaedic surgeons

whenever interosseous membrane lesions were suspected. They consisted

for each patient in a standard X Ray, CT scan and either a MRI and/or an

US.

Results: Depending on the use of either x ray or MRI/US, lesions of the

interosseous membrane were detected indirectly or directly respectively.

Radiological diagnose using MRI or US appears more efficient but can be

sometimes difficult to perform due to technical restrictions.

Conclusion: The presence of post-traumatic lesions of interosseous

membrane can be demonstrated by means of radiological tools. This

can lead to different treatment aiming at the best functional recovery

possible.

High-resolution ultrasound visualization of the intermediate and me-

dial femoral cutaneous nerves—normal and pathologic findings

G. J. Riegler, J. Mayer, C. Pivec, H. Platzgummer, P. Brugger, G. Bodner;

Vienna/AT

Purpose: Sensory skin innervation in the anteromedial thigh is provided

by the intermediate (IFCN) and medial femoral cutaneous nerves

(MFCN). Most reported neuropathies of the branches are related

to iatrogenic complications, and diagnosis is challenging. This

study aimed to evaluate the possibility of the visualization and

diagnostic assessment of the IFCN and MFCN with high-

resolution-ultrasound (HRUS).

Methods and Materials: In this prospective study, HRUS with

high-frequency probes (15-22MhZ) was used to locate the IFCN

and MFCN in 16 fresh cadaveric lower limbs. The correct iden-

tification of the nerves was verified by ink-marking and consec-

utive dissection. The visibility of the branches was rated on a

five-point scale (1= not visible, 5 excellent) on three different

locations (origin, mid-part, and most distal part of the nerve).

Moreover, landmark-based anatomical ultrasound maps of the

nerves were collected to simplify accurate identification. Cases

referred to our clinic for HRUS examinations because of

suspected IFCN and MFCN lesions were also assessed.

Results: Dissection confirmed the correct identification of the IFCN in

16/16 limbs (100%) and of the MFCN in 14/16 limbs (88%). The

visibility-median score was 5 at the mid-part and most distal part,

and 4 at the origin for both branches. Eleven cases of patients

with IFCN and MFCN pathologies (all of iatrogenic origin) were

identified. Seven instances of structural damage were visible on

HRUS, and all pathologies were confirmed by almost complete

resolution of symptoms after selective HRUS-guided blocks. All

IFCN cases were located in the inguinal region, whereas all

MFCN cases were present in the knee region.

Conclusion: This study confirms the reliable ability to visualize the IFCN

and MFCN with HRUS throughout the course of these nerves, both in

anatomical specimens and in vivo. We, therefore, encourage the use of

HRUS in patients with postoperative pain of unclear origin in the inguinal

or knee region.

Saturday, June 17

Scientific Paper Session –Knee

Uncovering of the anterior medial meniscus - a sign of posterior

cruciate ligament deficiency

A. P. Parkar, K. Bleskestad, S. Løken, E. Solheim; Bergen/NO

Purpose: Isolated posterior cruciate ligament (PCL) injury is uncommon

with an annual incidence of 2/100 000. Studies state that fibres may appear

continuous on MRI, leading to false negatives in up to 40% of chronic PCL

injuries. Passive posterior sagging (PPS) of the medial tibia is proposed as a

secondary sign for detecting chronic PCL injury on routine MRI. However,

we observe this regularly also in PCL intact knees, but we noticed unc-

overing of the anterior medial meniscus (UNCAMM) after PCL rupture.

We aimed to evaluate whether UNCAMM could be a more reliable sign of

PCL deficiency on routine MRI.

Methods and Materials: A retrospective PACS search of patients with

preoperative MRI, who had undergone a PCL reconstruction between

2011-2016 in our hospital was done. Patients who had undergone com-

bined ACL and PCL reconstruction, had a medial meniscal rupture or

fracture were excluded. In all cases three observers, one radiologist and

two medical students, recorded simple PPS and UNCAMM dichoto-

mously, and also measured the degree of PPS and UNCAMM in

millimetres A defined protocol was used for measurements. The same

data was recorded and measured in an age matched control group.

Statistical analysis of variability and reliability were performed.

Results: After applying the inclusion and exclusion criteria 32 patients

were reduced to 10patients in the PCL rupture group (PCLrup), 15 in the

control group (Cntrl).PCLrup included 4 male, 6 female, mean age 28.

Cntrl included 8 male, 7 female, mean age 27.

PPS was observed in 8/10 (80%) of PCLrp, and 5/15 (33%) in Cntrl, p=0.02.

UNCAMM was seen in 10/10 of PCLrup, and 6/15 (40%) of Cntrl, p=0.02.

PPS measured 4.8mm (± 4.4mm) in PCLrup and 1.8mm(±2.9mm) in

Cntrl, p=0.05. UNCAMM measured 3.6mm (±0.6mm) in PCLrup and

0.7mm(±0.9mm) in Cntrl, p= 0.004.

The Intraclass correlations (ICC) for interrater realibility were; PSS: 0.89,

PSS measurement: 0.98, UNCAMM: 0.96, UNCAMM measurement: 0.95.

Conclusion: Overall interrater reliability was high for all signs and mea-

surements. The presence of simple UNCAMM or PPS is not helpful in

identifying PCL deficient knees. A signifcant threshold of PPS measure-

ment to differentiate intact or deficient PCL was not observed in our study.

We find that UNCAMM ≥3 mm in the otherwise normal medial meniscus

suggests PCL deficiency on routine MRI. A prospective study to validate

this sign in a clinical setting would be beneficial.

Morel-Lavallée lesions of the knee: An MRI/Cadaveric study de-

scribing imaging features and suggesting an explanation for their

usual location

E. Vassalou

,V.Raoulis

, I. Tsifountoudis

,A.Zibis

, A. Karantanas

;

Heraklion, Crete/GR,

Larissa/GR,

Thessaloniki/GR

Purpose: To describe the MRI findings and treatment decisions/outcome

for Morel-Lavallée lesions (MLL) of the knee and to investigate whether

there is evidence supporting increased incidence of their occurrence in the

medial or lateral side, by performing a cadaveric experiment.

858 Skeletal Radiol (2017) 46:845–871

Methods and Materials: Within a 4-year-period, MRI studies of patients

with a clinical and MRI diagnosis of knee MLL were retrospectively

reviewed. Demographics, clinical data, mechanism of injury and treat-

ment decisions/outcome were available for all patients. MLL were cate-

gorized according to a widely used MRI classification system. For the

cadaveric experiment 20 fresh frozen knees were studied. A18-gouge

needle, adjusted to an intra-compartmental pressure monitor device,

was inserted into the space between the superficial and deep fascia of

the medial and lateral knee under ultrasound guidance. Following con-

stant injection of 10 cc of saline into this area the compartmental pressure

was monitored. The maximum compartmental pressures of the medial/

lateral side were recorded.

Results: Nineteen patients with knee MLL were identified (13 males, 6

females; mean age: 45.1 years, age range: 15-77 years). Twelve patients

had MLL of the right while 7 of the left knee. In 10 and 2 patients the

MLL were located in the medial and lateral aspect of the knee respective-

ly. In 7 patients both sides were affected, with a medial predominance. All

patients had sustained a direct impaction knee injury. Six of them were

injured during sports activities, 4 were involved in motor vehicle colli-

sions and 9 had a history of accidental fall. One patient was under

anticoagulation therapy. The mean time from injury to MRI scan was

6.6 days (range: 1-42 days). MLL were classified as type I, II and III in

9, 8 and 2 patients, respectively. MRI type was correlated with the chro-

nicity of the injury (r2: 0.763; P=0.0001). All patients were treated con-

servatively. Clinical examination verified complete resolution in all cases.

During the cadaveric experiment, an increasing compartmental pressure

following the saline injection was recorded, for both the medial and lateral

side. At the point the subcutaneous tissue separated from the fixed under-

lying deep fascia the pressure decreased acutely with a give-up phenom-

enon. The maximum compartmental pressures of the lateral side were

significantly higher compared with the medial side (P<0.05).

Conclusion: MLL of the knee demonstrate variable MRI patterns, corre-

lating with chronicity. The lower compartmental pressures of the medial

side of the knee may explain the higher incidence of MLL in this location.

Evaluation of a 3D accelerated SPACE sequence with compressed

sensing and free-stop scan mode for imaging of the knee

B. Henninger

,E.Raithel

,C.Kranewitter

,W.Jaschke

,C.Kremser

;

Innsbruck/AT,

Erlangen/DE

Purpose: To prospectively evaluate a new 3D turbo spin echo-based

proton-density weighted SPACE sequence prototype with compressed

sensing and a free-stop scan mode for preventing motion artefacts (PD-

SPACE-CS free-stop) in imaging the knee compared to conventional and

routinely used 2D sequences in a clinical setting.

Methods and Materials: A total of 73 magnetic resonance imaging

examinations of the knee (3.0T, Skyra, Siemens, Erlangen, Germany) in

71 patients (mean age 44years, range 18-84years, 35 female and 36 male)

were evaluated by 2 radiologists. All patients were examined with our 2D

routine protocol (coronal T1 and PD fs, sagittal and axial PD fs) and with

the PD SPACE CS free-stop. In case of a scan-stop caused by motion

(images are nevertheless calculated from, until this point acquired, raw-

data) the sequence was repeated without free-stop mode. Image quality of

the PD-SPACE-CS (with and without free-stop) as well as bone, cartilage,

meniscus, cruciate and collateral ligaments were evaluated and compared

to our reference 2D sequences. Inconclusive results between the 2 radi-

ologists were re-evaluated and a final decision was made in consensus.

Results: Image quality of the PD-SPACE-CS free-stop was found optimal

in 48/73, SNR was found slightly decreased in 16/73, moderately in 7/73

and severe in 2/73. In 25/73 examinations the free-stop scan mode stopped

the PD-SPACE-CS due to subject motion. The image quality with free-stop

showed a strong correlation (r=0.727, p<0.05) with the effective acquisition

time and therefore with the activation of the scan-stop. In case of a scan-

stop the image quality of the PD-SPACE-CS without free-stop was found

equal in 7/25, SNR was slightly increased in 7/25, improved with equal

contours in 3/25, improved with sharper contours in 7/25 and in 1 case the

quality of the free-stop was rated even better. Evaluation of the mentioned

knee-structures showed a high agreement between the results from the PD-

SPACE-CS and our 2D routine protocol (Chi-squared test of independence:

p<0.001; Cohen’s Kappa = 0.929 - 1).

Conclusion: PD-SPACE-CS with free-stop mode allows accurate imag-

ing of the knee with acceptable acquisition times. It is a reliable alterna-

tive for standard 2D protocols and other time-consuming 3D sequences.

Quantitative T2* relaxationtimes of articular cartilage of the knee in

elite professional soccer players in comparison to age- and BMI-

matched healthy individuals

M. Regier, G. H. Welsch, M. Kaul, G. Adam, C. Behzadi; Hamburg/DE

Purpose: To quantitatively assess articular cartilage of the knee in elite

professional soccer players by performing T2* relaxation measurements

and to compare the results to age- and BMI-matched individuals.

Methods and Materials: 22 elite professional soccer players and 22 age-

matched normal individuals were evaluated. All participants underwent

knee MRI at 3T with a qualitative and quantitative analysis. For quanti-

tative analysis T2* (22 echoes ranging from 4.6-53.6 ms; image resolu-

tion 0.5x2x2mm) measurements in 3D data acquisition were performed

in sagittal orientation. Qualitative analysis included e.g. meniscal tears,

joint effusion and bone edema. All data sets were postprocessed using a

dedicated software tool (qMapit) and quantitative maps were generated.

The deep and superficials layer of 22 predefined cartilage segments were

analysed. Statistical analysis included student t-test, confidence intervals

and a random effects model.

Results: In both groups, T2* relaxation times were significantly higher in

the superficial compared to the deep layers (p<0.001). In total, a mean

higher relaxation time of 2.5 ms was noted for professional compared to

amateur athletes p<0.001). Highly significant differences were found in

the three weight-bearing segments of the lateral superficial femoral con-

dyle (p>0.001).

Conclusion: A trend towards elevated T2* values in cartilage layers of

elite professional soccer players when compared to healthy individuals was

found. The effects seem to predominate in superficial layers. Longitudinal

studies have to show if these results represent early subtle cartilage leasions

prior to clinical manifestation, or possible adaption of the superficial carti-

lage layer to increased load and shear forces in the joint.

Comparison of T2 relaxation times of anterolateral femoral cartilage

in patients after ACL-repair with and without femoral notch sign

compared to healthy individuals

M. Regier, G. H. Welsch, J.-P. Petersen, M. Kaul, G. Adam, C. Behzadi;

Hamburg/DE

Purpose: To quantitatively assess cartilage of the femoral condyle in

patients after ACL-repair with and without femoral notch sign in initial

MRI and to compare the results to healthy individuals.

Methods and Materials: 58 patients underwent knee MRI at 3T at 6 to

24 months after ACL-rupture and surgical treatment and were matched to

Skeletal Radiol (2017) 46:845–871 859

20 healthy individuals. 27 of 58 re-evaluated patients had a positive

femoral notch sign in post-traumatic MRI. For quantitative analysis, in

all participants T2 relaxation measurement (7 TE: 10-70 ms) was per-

formed in sagittal orientation. By using the initial MRI after ACL-rupture

as aid to orientation, a polygonal region-of-interest (ROI) was placed in

the T2 map in the anterolateral femoral cartilage in each participant

encompassing the full cartilage layer. Statistical analysis included student

t-test and 95%-confidence intervals.

Results: Patients after ACL-rupture had significantly higher T2 relaxa-

tion times compared to healthy individuals (p<0.001). In patients with a

positive femoral notch sign, T2 relaxation times of the anterolateral fem-

oral condyle were significantly higher compared to patients without a

deep femoral notch as well as the control group (p<0.001). In total, a

mean higher relaxation time of 4.5 ms was noted compared to patients

with a negative femoral notch sign.

Conclusion: A trend towards elevated T2 relaxation times in the antero-

lateral femoral cartilage in patients with a positive femoral notch sign after

ACL-rupture was noted compared to patients without a deep femoral

notch. Therefore, a positive femoral notch sign at initial MRI seems to

be associated with higher cartilage degradation and further longitudinal

studies should be encouraged to investigate its clinical importance.

Intra-articular application of pulsed radiofrequency for pain reduc-

tion and mobility improvement in osteoarthritis of the knee joint

D. Filippiadis

,G.Velonakis

,A.Mazioti

, K. Palialexis

,E.Brountzos

N. L. Kelekis

,A.Kelekis

;

Athens/GR,

Haidari/GR

Purpose: To prospectively evaluate the safety an deffectiveness of intra-

articular application of pulsed radiofrequency (PRF) in symptomatic pa-

tients with knee osteoarthritis.

Methods and Materials: During a 30-month period, PRF was performed

on 53 cases of knee osteoarthritis (45 patients, 8/45 with bilateral knee

osteoarthritis). A 20G/10cm cannula was percutaneously inserted from

the antero-lateral region of the knee joint under fluoroscopy. Coaxially, a

RF electrode (10-mm “active tip”) was introduced and neurolysis session

was performed with PRF (1,200 pulses at 50 V with 10-ms duration

followed by a 480-ms silent phase). Following, intra-articular injection

of hyaluronate was performed. Pain, prior, one week/one, 6 and 12

months post were compared by means of a numeric visual scale (NVS)

questionnaire.

Results: Mean pain scores prior to PRF WAS 8.19± 1.4 NVS units. This

score was reduced to a mean value of 2.47 ± 2.5 NVS units at 1 week

after, 2.55±2.6 at 1 month, 3.1 ± 2.8 at 6 months and 5.02± 3.09 at 12

months of follow-up (p<0.01). Overall mobility improved in 47/53

(88.6%) patients. No complication was observed.

Conclusion: PRF seems to be an effective and safe technique for pallia-

tive management of chronic pain in patients with knee osteoarthritis.

Results seem to be reproducible and lasting longer that intra-articular

injection of hyaluronate solely performed.

Changes and associations of biochemical zonal chondral T2*-map-

ping in the knee joint and cartilage oligomeric matrix protein levels

during a TransEurope FootRace over 4.486 km

U. H. W. Schütz

, C. Nuesch

, C. Klenk

, A. Schmidt-Trucksäss

,M.

Brix

,S.Trattnig

, G. Pagenstert

, C. Billich

,M.Beer

,A.

Mündermann

;

Ulm/DE,

Basel/CH,

St. Pölten/AT,

Vie n na/AT

Purpose: From Bari to the North Cape –this was the route of the

TransEurope-Footrace (TEFR) over 4.486km (43 to 92km daily over 9

weeks) which was accompanied by a mobile 1.5T MRI. T2*-relaxation is

a potential parameter for the biochemical assessment of articular cartilage

and is related to the extracellular network and water content. Serum con-

centrations of cartilage oligomeric matrix protein (COMP) is used as

surrogate for cartilage turnover, and COMP-levels are known to continue

to increase throughout prolonged running. The purpose of this study was

to evaluate morphological and biochemical changes in the knee cartilage

and their potential association to the effects of transcontinental multistage

ultra-running on serum COMP-levels.

Methods and Materials: Twenty-two of 67 TEFR-participants were

enrolledand received a baseline MRI and serum sampling before the

run and 3-4 times during the TEFR. For biochemical cartilage analysis

T2*-relaxation times (FLASH T2*-GRE) were obtained from online re-

constructed T2*-maps (mono-exponential nonnegative least-squares-fit-

analysis). TIRM and fat saturated PDw-sequences were obtained for

morphologic image evaluation. Mean cartilage height and T2*-profiles

were calculated on specific areas (ROIs). Serum COMP-levels were de-

termined using ELISAs. Statistical data analyses regarding changes of the

outcome parameters during the TEFR and possible confounding factors

(running burden, BMI, age, sex) were performed (P<.05).

Results: Cartilage thickness and T2* in the patellofemoral cartilage did

not change significantly but cartilage thickness of the anterior

femorotibial cartilage decreased throughout the race in subjects younger

than 50years. A significant increase in mean COMP-levels and in

intrachondral T2* in all femorotibial ROIs occurred after 1,000km and

remained at a steady state until the end of the TEFR. Individual changes

in COMP-levels did not correlate with T2*, and individual changes in

these parameters were not related to any obvious confounding factor

(P>0.80 and P>0.59, respectively). Preexisting joint lesions did not

change, and new ones were observed during TEFR.

Conclusion: Changes in tibiofemoral but not patellofemoral cartilage

suggest that the patellofemoral joint does not seem to receive relevant

mechanical stimulation during transcontinental running. It appears that

cartilage adapts to the running load in the first 1,000km and is able to

withstand the high mechanical demands of the race. The lack of correla-

tion of individual changes in COMP-levels and T2*-values confirms that

T2*-relaxation time reflects overall structural changes of the extracellular

matrix and not of specific constituents such as COMP. Our results suggest

that multistage ultramarathon running does not increase the risk of general

or local cartilage degeneration.

Role of MRI to predict meniscal tears reparability

P. Felisaz

, F. Alessandrino

, S. Perelli

, G. Zanon

, F. Calliada

,F.

Benazzo

, L. Sammarchi

;

Milan/IT,

Pavia/IT

Purpose: Arthroscopic treatment of meniscal tears includes partial

meniscectomy and meniscal repair. Repair is suitable in young subjects

with tears located in the vascularized red-zone. The type of the tear is a

key factor as well, considering that vertical tears are more amenable to

repair, horizontal are less frequently repaired and radial, complex or flaps

have poor chances to heal if repaired. Previous authors suggested that

MRI is a poor predictor of tear reparability but have not taken into con-

sideration the tear type in the analyses or have studied a single type of

tears. The aim of this study was to elucidate the role of MRI in predicting

meniscal tears reparability; parameters of interest were the tear type (ver-

tical, horizontal, radial, complex, flaps and bucket handle) and location in

relation to vascular zones.

Methods and Materials: We retrospectively evaluated 79 pre-surgical

MRIs of meniscal tears arthroscopically treated with meniscectomy or

860 Skeletal Radiol (2017) 46:845–871

meniscal repair. We developed an algorithm and classifiedtears according

to their type: vertical, bucket-handle and horizontal tears were considered

reparable if the distance measured from the tear to the menisco-sinovial

junction was less or equal to 5 mm; radial, complex and flap tears were

directly considered non-reparable. MRI predictions were compared with

the arthroscopic outcome.

Results: MRI had a sensitivity of 88%, specificity of 77%, PPVof 86%,

NPV of 79% and accuracy of 84% in predicting meniscal tears

reparability. Agreement between MRI and arthroscopy was good (k =

0.65). The ROC curve analysis demonstrated AUC of 0.91 for the vertical

tears, but only of 0.76 for the horizontal tears. ACL injury and the medial

side were positively correlated to reparation. Accuracy of MRI in detect-

ing the tear pattern eventually revealed during arthroscopy was 96%.

Conclusion: In this study we have shown that the tear type is a key point

to predict meniscal tears reparability, along with the tear location in re-

spect of the vascular zones and age. radial, flaps and complex tears have

poor chances to heal and to be repaired. Vertical tears can be repaired if

located at a maximum of 4 mm from the menisco-synovial junction with

levels of sensitivity 83% and specificity 81%. This cutoff may be slightly

reduced for bucket-handle tears and increased for horizontal tears. We

have concluded that MRI can be a reliable predicting tool of reparability

of meniscal tears if performed with defined standards and using our

criteria.

High-resolution ultrasound in acute meniscal tear diagnosis

S. P. Ivanoski

,O.Sesoski

, V. Vasilevska Nikodinovska

;

Ohrid/MK,

Skopje/MK

Purpose: The aim of the study was to assess the accuracy of high-

resolution ultrasound in diagnosis of tears of the medial and lateral me-

niscus in acute knee trauma, using arthroscopy as gold standard.

Methods and Materials: Menisci of 50 patients with acute knee trauma,

scheduled for knee arthroscopy, with clinical diagnosis of internal de-

rangement of knee were assessed using high-resolution ultrasound. 36

of the patients were men and 14 women, with mean age of 34.2 years

(age range 16-58 years). Ultrasound of the knee including evaluation of

both menisci was performed by a radiologist with 6 years’experience in

musculoskeletal ultrasound. High-resolution transducer with variable fre-

quency (13-5 MHz) was used for the exams. Arthroscopy was performed

within several days following ultrasound exam by orthopedic surgeons

experienced in knee arthroscopy.

Results: On arthroscopy 39 meniscal lesions were found, 23 medial and

16 lateral meniscal tears. True positive finding on ultrasound was present

in 20 medial menisci and 12 lateral menisci. 61 menisci were normal on

arthroscopy (27 medial and 34 lateral). True negative finding on

ultrasound was present in 23 medial and 29 lateral menisci.

Overall sensitivity, specificity, positive and negative predictive

value were 82%, 85.2%, 78% and 88.1% respectively. Sensitivity was

higher for medial meniscal tear (86.9%, compared to 75% for lateral

meniscal tear). Specificity was similar for both menisci (85.2 for

medial and 85.3 for lateral meniscal tear). Positive and negative

predictive value were both higher for medial meniscal tear (83.3%

and 88.5% for medial and 70.6% and 87.9% for lateral meniscal

tear). Overall accuracy was 84%, 86% for medial meniscal tear

and 82% for lateral meniscal tear

Conclusion: Overall sensitivity, specificity and accuracy of high-

resolution ultrasound in acute meniscal tear are relatively high.

Although sensitivity and accuracy are higher for the medial meniscal tear,

ultrasound can be an adequate method for initial evaluation of acute

meniscal tears of both menisci. However, radiologists should be aware

of its limitations and weaknesses.

The diagnostic yield and role of image guided tissue sampling in the

diagnosis of chronic Total Knee Joint Replacement infection: our

single centre experience

L. Wing, A. C. Macdonald, K. Partington; Oxford/UK

Purpose: Accurate diagnosis of prosthesis infection following Total Knee

Joint Replacement (TKJR) is of critical importance, particularly given the

implications for morbidity, including revision surgery. Current investigations

are limited by poor sensitivity and specificity. We present our institution’s

experience of image-guided tissue biopsy and its role in the diagnosis of

chronic TKJR infection.Fluoroscopic guided biopsy is a procedure during

which peri-prosthetic lucency identified on plain radiography is targeted.

Ultrasound guided synovial biopsy involves use of a biopsy needle to obtain

samples of synovium and/or with joint aspiration simultaneously.

Methods and Materials: Retrospective search of our Radiology

Information System (RIS) was performed to identify patients who had

undergone fluoroscopic or ultrasound guided tissue biopsy or joint aspira-

tion for suspected chronic TKJR infection over a two-year period.The

Electronic Patient Record (ePR) was searched to collate: contemporaneous

CRP, microbiology and histology results, and subsequent surgery results.

Results: 64 patients underwent ultrasound guided synovial biopsy yield-

ing 6 true positive and 11 false positive results. There were 43 true neg-

ative and 4 false negative results.Ascertaining a sensitivity of 60% and

specificity of 80%, which equated to positive predictive value (PPV) of

91% and negative predictive value (NPV) of 35%.12 patients underwent

fluoroscopic guided biopsy yielding 0 true positive and 2 false positive

results. There were 9 true negative and 1 false negative

results.Ascertaining a sensitivity of 0% and specificity of 82%, PPV of

90% and NPVof 0%.78 patients underwent ultrasound guided aspiration

yielding 5 true positive and 31 false positive results. There were 38 true

negative and 4 false negative results.Ascertaining a sensitivity of 55% and

specificity of 55%, PPV of 90% and NPV of 13%.

No adverse complications were documented following sampling.

Conclusion: Although there is overlap in the use of the three image-

guided procedures, they are useful in the diagnosis of chronic prosthetic

joint infection and in identification of specific pathogens under varying

circumstances (e.g. radiographic appearances, presence of effusion).

Furthermore, these procedures appear safe.Ultrasound guided synovial

biopsy offers enhanced sensitivity and specificity to aspiration. Whilst

poorly sensitive, fluoroscopic guided biopsy offers a high specificity

which may be of use in selected circumstances.We suggest an algorithm

for radiological investigation of chronic prosthetic joint infection, based

on radiographic and diagnostic ultrasound findings.

MRI features of post-arthroscopy pain syndrome (PAPS):

Correlation with preoperative imaging and up to four years of follow

D. Dalili, M. Bansal, N. Khandwalla, Z. Shah, M. George, M. J. Bankes,

A. Isaac;London/UK

Purpose: To analyse literature-described MRI findings seen in patients

presenting with new onset or persistent pain following hip arthroscopy for

femoroacetabular impingement (FAI).

Methods and Materials: PAPS was observed in 84 out of 510 patients

seen in our institution, who underwent arthroscopy between January 2013

and December 2015.

We analysed the interval MRI studies performed for all 84 consecutive

patients who presented with PAPS, within 3 months of arthroscopy.

Skeletal Radiol (2017) 46:845–871 861

We compared the findings seen on MRI with the preoperative MRI stud-

ies performed up to 6 months prior.

In addition, we correlate the MRI findings with other modalities per-

formed within the same time period (Plain radiographs/CT preoperatively

and plain films and SPECT CT and /or US post arthroscopy).

Results: The MRI’s demonstrated:

Conclusion: Most causes of PAPS are transient, with little/no underlying

residual bony or soft tissue damage.

FAI is related to other developmental abnormalities, affecting other joints.

The mechanical effect of these abnormalities remains poorly understood.

Future research is required to evaluate the pelvis as one unit formed of

several components, namely two SIJs, two hip joints, lumbosacral junc-

tion and symphysis pubis, rather than the current model of “stand alone”

joints. This would have an impact on planning management and

rehabilitation.

Understanding the various causes of PAPS would enable the radiologist

to tailor the imaging required for more definitive diagnoses.

Comparison with pre-arthroscopy imaging, confirms interval change and

real true findings, particularly those of the labrum and other joints related

to the pelvic “unit”.

Microstructural evaluation of the anterior cruciate ligament (ACL)

with MR-diffusion tensor imaging (DTI): Further experience

I. P. Voicu

, L. Di Clemente

, R. Navarra

, P. A. Mattei

,V.Calvisi

,A.R.

Cotroneo

, M. Caulo

;

Chieti/IT,

L'Aquila/IT

Purpose: To assess if DTI metrics are correlated with microstructural

anatomy of the anterior cruciate ligament (ACL) and with knee stability.

Methods and Materials: We examined both knees of 48 subjects: 23

healthy controls (11F, age 20-40) and 25 patients with previous ACL

injury (9F, age 20-40). All subjects underwent routine clinical orthopedic

examination (that included anterior drawer, Lachman and Jerk tests) and

KT-1000 arthrometer evaluation. Clinical examination and KT-1000

evaluation were performed by an experienced orthopedic surgeon

(V.C). By means of arthrometer evaluation compliance index (CI) was

obtained. Thereafter, an MR scan on a 1.5 T magnet was obtained in all

subjects. MR imaging protocol included conventional sequences and ax-

ial DTI sequences with 15 gradient directions (repetition time (TR)/echo

time (TE) 9,2 ms/4,3 ms; acquisition matrix 92x92 mm; slice thickness

1,6 mm (contiguous); b-value = 600, total scan time: 3:06). Quantitative

analysis was performed by overlapping DTI sequences to T2 sequences.

Differences of Fractional Anisotropy (FA) of ACLs between knees in

healthy controls and patients were evaluated with a paired t-test.

Results: No significant differences were found between ACL FA values

of right and left knees in healthy controls. Significant differences were

found between ACL FA values of healthy and injured knees in the pa-

tients group (n=25; FA: 0,7221 ± 0.09 vs 0,6117 ± 0.12, p<0,01).

A comparison between healthy and injured ACLs in a healthy control

(a,b) and an injured patient (c,d). The healthy control ACL had an FA

value of 0.71. The patient injured ACL had an FA value of 0.48, clinical

instability and underwent surgical repair.

Conclusion: DTI is feasible for the study of the integrity of the ACL.

Among DTI metrics, FAvalues showed the most promising results for the

evaluation of ACL post-traumatic injury. In healthy controls, no signifi-

cant differences were found between FA values of ACL in right and left

knees. In the patients group significant differences were found between

ACL FA values of healthy and injured knees. Our previous findings are

therefore confirmed on a larger series of patients. Further studies are

required to determine if DTI FA could be used for early diagnostic, treat-

ment evaluation and prognosis of ACL injuries.

Anterior cruciate ligament pathology as a predisposing factor for

bucket handle tear of medial meniscus

O. M. Albtoush, K. Nikolaou, M. Notohamiprodjo; Tübingen/DE

Purpose: To ascertain that presence of anterior cruciate ligament pathol-

ogy is a predisposing factor for the occurrence of bucket handle tear of the

medial meniscus.

Methods and Materials: Retrospective PACS-search and evaluation of

consecutive 1850 knee MRI examination from May 2013 to January

2017 with various 1.5 and 3T MRI machines has been done in university

of Tuebingen, looking for cases with displaced bucket-handle tear of the

medial meniscus. Initial screening was performed by one reader. The

identified cases were evaluated by two readers.

From the resulted cases with bucket handle tear of the medial meniscus, a

thorough evaluation was done to include only those with the availability

of previous MRI examination prior to the occurrence of the bucket handle

tear or longitudinal tear along medial meniscus.

Results: From the evaluated 1850 knee MRI-scans 27 cases with bucket

handle tear of the medial meniscus were identified. 15 male and 12 female

patients.Average age included was 40 years. From the identified 27 cases

only six cases had previous MRI-scan with no evidence of bucket handle

tear or longitudinal tear along the medial meniscus.

Interestingly, all the finally resulted six cases showed a clear anterior

cruciate ligament abnormality prior to the occurrence of bucket handle

tear. The pathologies of the associated anterior cruciate ligament abnor-

malities ranged from partial tear (n=2), complete tear (n= 1) and previous

ACL-repair (n=3). No increased incidence of medial collateral ligament,

Posterior cruciate ligament, Lateral collateral ligament or lateralmeniscus

pathology were noted.

Conclusion: ACL pathology appears to be a crucial predisposing factor

for the occurrence of bucket handle tear of medial meniscus. This result

delineates a significant temporal association between these types of inju-

ries in the knee joint, as well as underlines addressing the medial menis-

cus during ACL-repair and the importance of its follow up.

Saturday, June 17

Scientific Paper Session - Tumor and other

Cementoplasty for managing painful bone metastases outside the

spine

G. Sun; Jinan/CN

Purpose: To illustrate the effect of treatment with cementoplasty in pa-

tients with painful bone metastases in the extraspinal region.

Methods and Materials: A retrospective study was conducted to review

87 consecutive patients who underwent cementoplasty under CT or fluo-

roscopic guidance, a total of 102 lesions involving the ilium, ischium,

pubis, acetabulum, humeral, femur and tibia. In 36 patients with a high

risk of impending fracture in longbones based on Mirels’scoring system,

percutaneous long bone cementoplasty (PLBC) alone was performed in

19 patients, PLBC with a cement-filled catheter in the medullary canal

(ECFC) was applied in 17 cases. The clinical effects were evaluated using

the visual analogue scale (VAS) preoperatively and postoperatively.

Results: All patients were performed with cementoplasty successfully.

Cement leakage was found in 21 lesions without any symptoms. VAS

862 Skeletal Radiol (2017) 46:845–871

scores decreased from 8.19±1.1 preoperatively to 4.94± 1.6 at 3 days,

3.41±2.1 at 1 month and 3.02±1.9 at 3 months, 3.13±2.3 at 6 months,

postoperatively. There was a significant difference between the mean

preoperative baseline score and the mean score at all of the postoperative

follow-up points (P <0.01). In 36 patients with a high risk of impending

fracture in long bones, five patients with PLBC alone experienced path-

ological fractures of the treated long bone during daily activity at the 1.5-,

2-, 3- and 6-month follow-ups. No patients with PLBC and

ECFCexperienced pathological fractures of the treated long bone.

Conclusion: Cementoplasty is an effective technique for treating painful

bone metastases in extraspinal regions, which is a valuable, minimally

invasive, method, Combined PLBC and ECFC is a safe and effective

procedure for long bone metastases with impending fracture.

Bone involvement in extranodal Hodgkin disease: diagnostic

methods compared

P. Pedote, V. Alberotanza, F. Gaudio, C. Ferrari, R. Virelli, A. Ferrante,

G. Rubini, G. Angelelli; Bari/IT

Purpose: Initial staging is crucial for demonstrating the presence of

extranodal involvement, which will affect therapeutic decisions.

Osseous involvement in Hodgkin Disease (HD) occurs in only 1%–4%

at presentation. The aim of our study was to evaluate the role of contrast-

enhanced CT (CECT), MRI and 18FDG-PET/CT (PET / CT) for detec-

tion of HD bone localizations.

Methods and Materials: We retrospectively selected 18 patients with

bone involvement in HD histological diagnosis (16 Nodular sclerosing, 2

Mixed-cellularity). All patients underwent CECT, MRI and PET/CT for

initial staging within 15 days of each other. The diagnostic accuracy has

been calculated for each technique, considering outcome of bone biopsy

as gold standard. Mc Nemar test was used to compare performance of the

three diagnostic methods (p <0.05).

Results: 18 bone lesions biopsied, 10 were found to CECT, 18 MRI and

18 PET / CT. In 10/18 patients (55.6%) there was correlation between the

three methods. CECT diagnostic accuracy was 55.6%, MRI and PET/CT

100%. The MRI and PET / CT performance showed a statistically signif-

icant difference compared to CECT (p = 0.013).

Conclusion: MRI and PET/CT are more accurated than CECT, in the

study of HD extranodal bone involvement. Their performances are sta-

tistically better than CECT thus decreasing the risk of understaging and

optimizing therapeutic management.

Extraspinal Percutaneous Osteoplasty for the Treatment of Painful

Bony Metastasis

K.-H. Kim; Yangsan/KR

Purpose: Extraspinal percutaneous osteoplasties (POPs) are novel tech-

niques for the treatment of painful bony metastasis, which is often the

cause of both persistent and incidental breakthrough pain. This retrospec-

tive study explored the efficacy and complications of extraspinal POPs.

Methods and Materials: The origin of the cancer metastasis, performed

POP sites, necessity of adjacent joint injections, pain and Karnofsky per-

formance scale (KPS) scores, complications related to the POPs, and life

expectancy were evaluated from the medical records from 2009 to 2016.

Results: A total of 48 (M/F = 27/21) patients had received 55 POPs,

including costoplasty, scapuloplasty, ilioplasty, humeroplasty,

ischioplasty, femoroplasty, sternoplasty, and puboplasty, in order of fre-

quency. The most common sites for the origin of the cancer, in order of

frequency, were the lung, liver, breast, colon, and kidney. All patients

receiving POPs including scapuloplasty, ilioplasty, humeroplasty, and

femoroplasty needed adjacent joint injections before or after the POPs.

Pain due to metastatic lesions was reduced significantly immediately after

the POPs and sustained until the end of their lives. The median KPS was

increased from 35.4% to 67.7% immediately after the POPs. There were

no complications related to the procedures. The mean life expectancy

after performing the POPs, for 35 patients which died afterwards, was

99.3 days, ranging from 1 to 767 days.

Conclusion: Even though pain in the isolated POP sites may be difficult

to measure due to overlapping systemic pain, the POPs provided imme-

diate local pain relief, and the patients showed better physical perfor-

mance without procedure-related complications.

Shear-wave elastography with ultrasonography for discriminating

benign and malignant soft tissues tumors

N. E. Regnard

,A.Buisson

,S.Charlon

,E.Pluot

,F.P.Kuhn

,J.L.

Drape

, A. Feydy

, R. Campagna

;

Paris/FR,

Levallois-Perret/FR,

Champigny/Marne/FR,

Montrouge/ FR

Purpose: Only few imaging criteria exist for discriminating malignant

and benign soft tissue tumors.

The objective was to discriminate benign and malignant soft tissues tu-

mors with shear wave elastography

Methods and Materials: All patients were included consecutively

and prospectively in our institution. The multidisciplinary staff de-

cided a biopsy under ultrasonography guidance. All patients had ul-

trasonography with elastography mode (Toshiba Aplio 500, probe).

We excluded fatty soft tissue tumors. We assessed the size of the

tumor, the elasticity (value and ratio under subcutaneous fat), and

the histology of the tumor. We compared the group with benign soft

tissue tumors and malignant tumors.

Results: 100 tumors were included (45 malignant soft tumors and 55

benign soft tumors). The mean age was 43.8 ( +/- 16.7) in the benign

group and 48.1 (+/- 16.5) in the malignant group (p=0.21) . The greater

sizes were 45.5 mm (+/- 34.7) in the benign group vs 58.6 mm (+/- 41.8)

in the malignant group (p= 0.10). The average volumes .were 65.9 cc in

the benign group vs 292.cc in the malignant group (p=0.05). The average

ratio between elasticity of the tumor and subcutaneous fat was 5.41 in

malignant lesions vs 3.24 in benign lesions (p=0.11). The sensitivity of

this ratio to discriminate benign and malignant lesions was 77.3% and

specificity 69.1% with Area Under the Curve of 0.743 (p=0.001) with a

threshold superior to 1.712.

Conclusion: We can discriminate benign and malignant soft tissue tu-

mors with shear wave elastography using ultrasonography

T2-weighted SE Dixon sequence: a one-stop shop for the morpholog-

ical assessment of bone marrow metastases?

Y. Ma ed e r

, R. Richard

,V.Dunet

,F.Becce

,P.Omoumi

;

Lausanne/

CH,

Paris/FR

Purpose: We aimed to test the potential of Dixon fat only images to

replace T1-weighted sequences for the detection of bone metastases, by

comparing the diagnostic performance Protocol 1 (standard protocol):

Skeletal Radiol (2017) 46:845–871 863

sagittal spin echo T1-weighted (T1) and SE Dixon T2-weighted water

only (DixonT2Water) images and Protocol 2 (alternative protocol): sag-

ittal SE Dixon T2-weighted fat only (DixonT2Fat) and DixonT2Water

images.

Methods and Materials: 121 consecutive whole spine exams (63 males,

mean age=61.4±11.8) for suspected vertebral metastasis were retrospec-

tively included. Quantitative image analysis was performed for 30 ran-

domly selected spine levels. Qualitative analysis was performed by two

musculoskeletal radiologists who separately reviewed the two protocols.

The number of metastases was registered for each spine level. Diagnostic

performance of the protocols was compared using a chi-squared test of

equality of ROC curves, using a best valuable comparator as a reference.

Interobserver and interprotocol agreement was assessed using kappa

statistics.

Results: Contrast-to-noise (CNR) ratio was higher on DixonT2Fat than

T1 images (p<0.0001). Diagnostic performance was not statistically sig-

nificantly different between the two protocols for both readers, in a per-

patient analysis (Protocol 1 vs. 2: Se=93.6-97.9% vs. 97.9-98.9%;

Sp=92.6-96.3% vs. 85.2-92.6%; AUC=0.95 vs. 0.92-0.96; PPV=97.9-

98.9% vs. 95.8-97.9%; NPV=81.9-92.6% vs. 92-96.2%, all p>0.29)

and a per-spine level analysis (p>0.30), except for the cervical spine

(Protocol 2 better performance for one reader (p=0.026)). Interobserver

and interprotocol agreement was good to very good (kappa=0.70-0.81).

The average total acquisition time for Protocols 1 and 2 were 13min45sec

(+/- 1:23) and 9min25sec (+/- 1:24) respectively.

Conclusion: DixonT2Fat and DixonT2Water images provide, in one

sequence, higher CNR ratio with similar diagnostic performance to the

standard combination of morphological sequences for the detection of

spinal metastases, reducing acquisition time by about 32%.

Bone metastases: A complex disease, a multidisciplinary and

multimodality approach

A. Bazzocchi

,G. Facchini

, D. Mercatelli

, S. Guerri

, C. Gasperini

,M.

Aparisi Gomez

, G. Rossi

, E. Rimondi

, U. Albisinni

;

Bologna/IT,

Valencia/ES

Purpose: Bone is a usual site for metastases. Primary cancers that com-

monly metastasize to bone are the highest in incidency worldwide.

Population aging associated with the increasing incidence of cancer de-

mand for optimized strategies to improve survival, symptom-free time

and quality of life in affected patients. When cancer is at advanced stage

the treatment should bring to a chronic disease with the longest survival

and with cancer-related and treatment-related symptoms and quality of

life impairment as minimal as possible. Bone metastases cause bone pain,

fractures, hypercalcemia, spinal cord and nerve compression syndromes.

These are the most common cause of cancer-related pain, constituting a

huge burden for patients, health care and economy. The aim of this work

is to evaluate the efficacy of MRI-guided high-intensity-focused-

ultrasound therapy (MRIgHIFU) plus selective/superselective arterial

embolization with N-butyl-cyanoacrylate (EMBO) in the management

of bone metastases (local control at 3 months as primary endpoint).

Methods and Materials: Seventeen patients were enrolled in the study.

They were submitted to both MRIgHIFU and EMBO, with CT/MR be-

fore and 3 month after the last treatment performed and MD Anderson

criteria were used to assess tumor response. VAS score and quality of life

(EORTC QLQ-C15-PAL and -BM22) before and at 1, 3, 6 and 12 months

were used to evaluate clinical status.

Results: Out of 17 patients (7 females, 60.6±13.1 with range 24-82 years,

primary cancers: kidney [35.3%], thyroid [17.6%], lung and prostate

[11.8% each], and others [23.5%]), 10 underwent MRIgHIFU first, 7

underwent EMBO first, within a mean time of 5 months in between.

Baseline met dimension was 10.3±4.1cm, ranging 5.3-20.1cm, and

76.5% of them showed a purely lytic pattern. Seven lesions were previously

submitted to external-beam-radiation-therapy (EBRT). At 3 months, a com-

plete response was observed in 3 patients (25.0%), a partial response in 4

patients (33.3%), and disease remained stable in 5 patients (41.7%), with no

progression. No significant difference was found for patients previously

submitted to EBRT, or related to EMBO timing (pre/post). Local tumor

control was independent of VAS and questionnaires score changes.

Conclusion: Bone metastases should be approached by a multidisciplin-

ary team, with all the available techniques in mind for potential use in

treatment. This is fundamental to drive free and conscious therapeutic

choices. Although the magic bullet has still to be found, as the optimized

sequence and timing for the use of different techniques, a multimodality

approach seems to offer good results to control the disease.

Differentiation between benign and pathologic vertebral compres-

sion fractures using Golden-angle RAdial Sparse Parallel (GRASP)

Imaging

M. Garcia Alzamora

, M. Gloor

,T.K.Block

,B.Stieltjes

,O.Bieri

,D.

Harder

;

Basel/CH,

New York/US

Purpose: Pathologic vertebral body (VB) compression fractures may be

indistinguishable from benign compression fractures by conventional

MRI. The purpose was to analyze the use of a T1w3D sequence with

contrast for dynamic MR imaging (Golden-angle RAdial Sparse Parallel,

GRASP) for distinguishing pathologic from benign vertebral compres-

sion fractures.

Methods and Materials: Six patients with metastases in non-fractured

VBs (1m/5f; mean 60 years), six patients with VB compression fractures

without a history of a malignancy (2m/4f, mean 72 years), and four

patients with VB compression fractures caused by osseous metastases

(1m/3f, mean 64 years) obtained an MRI including GRASP T1w3D with

intravenous contrast administration at 1.5 or 3T (Siemens) with the fol-

lowing imaging parameters: TA 4:20 min, TR/TE 5.92/1.78 msec, slice

thickness 2.5 mm, matrix 256 x 256 mm, voxel size 1x1x2.5 mm. A

region of interest (ROI) was placed in the pathologic-appearing VB and

in a normal-appearing VB, the latter and the metastatic non-fractured VBs

serving as a reference.

Results: There was no difference in maximum contrast-enhancement in-

tensity between the three patient groups. All thee patient groups showed a

higher contrast-enhancement than the normal-appearing VBs. All VB frac-

tures without malignancy showed a time-contrast-enhancement intensity

course almost parallel to that of the normal-appearing VB composed of a

fast increase of contrast enhancement (at 40-80 sec) shortly afterwards

reaching a plateau (80-130 sec). In contrast, all metastases without a fracture

showed a slightly earlier and very fast increase of contrast-enhancement (at

30-55 sec) followed by a prolonged and weak decrease of enhancement

towards a late plateau (>175 sec). The time intensity contrast-enhancement

curves of the pathologic fractures showed the same pattern as the metastatic

non-fractured VBs (slope 38-55 sec, plateau >175 sec).

Conclusion: Pathologic VB fractures disclosed a different time intensity

contrast-enhancement curve than benign compression fractures. They

showed a similar contrast-enhancement behavior compared to

metastatic-infiltrated non-fractured VBs disclosing an earlier and faster

slope followed by a slight and prolonged contrast-enhancement decrease.

The different contrast-enhancement pattern between benign and patho-

logic VB fractures are presumably due to the different tissue composition

(cellularity) and vascularity of the bone. These preliminary data suggest

that dynamic GRASP imaging may be useful for the differentiation be-

tween benign and pathologic fractures, which may be of great value for

therapeutic management decision.

864 Skeletal Radiol (2017) 46:845–871

Solid Bone Tumors of the Spine: Diagnostic Performance of

Apparent Diffusion Coefficient Measured using Diffusion Weighted

MRI with Histology as a Reference Standard

D. Albano

,G.Pozzi

, R. Lagalla

,G.Perrucchini

,A.Luzzati

,L.M.

Sconfienza

;

Palermo/IT,

Milan/IT

Purpose: To assess diagnostic performance of mean apparent diffusion

coefficient (mADC) in differentiating benign from malignant bone tu-

mors of the spine, having histology as a reference standard.

Methods and Materials: We reviewed MRI images of 116 patients with

biopsy-proved spinal tumours (ST) who underwent 1.5 T MRI with T1,

T2 and DWI sequences between January 2010 and November 2016. Two

radiologists independently measured mADC placing region of in-

terest in both pathologic and normal bone and findings were

compared to histology (reference standard). ST were classified

into malignant primary tumours (MPT); bone metastases (BM);

and benign primary tumours (BPT). Kruskal-Wallis, Mann-

Whitney U, intraclass correlation coefficient (ICC) statistics were

used and approximate receiver operating characteristic curves

were calculated.

Results: The mADC values of MPT (n=35), BM (n=65) and BPT (n=16)

were 1.00±0.32 (0.59-2.10) ´ 10

-3

/s, 1.02±0.25 (0.73-1.96) ´ 10

-3

/s and 1.31±0.36 (0.83-2.14) ´ 10

-3

/s respectively. mADC was

significantly different between BPTand all malignant lesions (BM+MPT)

(P<0.001), between BM and BPT (P=0.008), and between MPT and BPT

(P=0.008). No difference was found between BM and MPT (P=0.999). A

mADC threshold of 0.952 ´ 10

-3

/s yielded 81.3% sensitivity, 55.0%

specificity. Accuracy was 76% (95% confidence interval = 63.9%-

88.1%). mADC measurements had almost perfect inter-observer repro-

ducibility (ICC=0.916; 95% confidence interval=0.879-0.942).

Conclusion: DWI with mADC quantification is reproducible tool to

differentiate benign from malignant solid spinal tumors with 76% accu-

racy. The mADC value of BPT are significantly higher than that of ma-

lignant tumors.

Shear-Wave Elastography Evaluation of the Rotator Cuff Muscles:

follow-up before and after tendon repair. A pilot study

S. Djebbar

,C.A.Agten

,A.Merkle

,C.J.Burke

, R. S. Adler

;

New

York City, NY/US,

Zurich/CH,

Durham, NC/US

Purpose: To describe the temporal changes in shear wave elastography

(SWE) in the rotator cuff muscles before and after surgical repair.

To determine if SWE could be a reliable method of early depiction in

muscles changes in rotator cuff tendon tears.

Methods and Materials: IRB approval and informed consent were ob-

tained for this prospective study. 12 patients underwent SWE ultrasound

of the supraspinatus (SSP) and infraspinatus (ISP) muscles on both sides

before (t0), 1 month (t1), and 3 months (t2) after surgical repair of a

rotator cuff tear on one side. Axial and longitudinal mean shear-wave

velocities (SWV) measurements were obtained for supraspinatus (SSP)

and infraspinatus (ISP) muscles at each examination. SWV changes in

each muscle and side over time were assessed (Friedman test, p<0.05)

and if a significant change was found Wilcoxon post-hoc testing (t0 vs. t1,

t0 vs. t2, t1 vs. t2) with 3-fold Bonferroni-adjusted p-values (p<0.0167)

was performed. SWV in the operated and non-operated side were

compared.

Results: Mean SWV in the SSP on the operated side were 3.3 (t0), 2.9

(t1), 2.8 (t2) for axial and 3.9, 3.6, 3.5 for longitudinal measurements,

respectively. On the non-operated side the values were 3.1, 3.6, 3.0 (axial)

and 4.4, 4.2, 3.4 (longitudinal). The change in MSV over time in the SSP

was not statistically significant (p=0.18-0.687). Mean SWV in the ISP on

the operated side were 3.3, 2.3, 2.4 (axial, p<0.0005) and 3.9, 2.7, 2.6

(longitudinal, p=0.042), on the non-operated side 3.5, 2.8, 2.5 (axial,

p=0.368) and 3.3, 2.8, 2.3 (longitudinal, p=0.015). Post-hoc analysis

showed a statistically significant MSV drop only for t0 vs. t1 for the

ISP axial on the operated side (p=0.009). Other post-hoc analyses showed

no statistically significant differences after Bonferroni-adjustment

(p=0.28-0.735). No differences were found for the MSV comparison

between the operated and non-operated side for each time point

(p=0.08-1).

Conclusion: SWE is a promising modality for the assessment of rotator

cuff's muscles in patients with pathology and following surgical repair.

SWV is a promising tool for early depiction and follow-up in muscle

changes in RCT pathology, but however requires further evaluation.

The prevalence of a sublabral recess in the anterosuperior glenoid

labrum

A. Nitschke

,M.Tuite

;

Fitchburg/US,

Ve ro n a / U S

Purpose: The normal anterosuperior glenoid labrum can have a variable

appearance on MRI due to several known anatomic variants. The

two most well known variants are a sublabral foramen and Buford

complex. The anterosuperior sublabral recess is a third variant,

however its prevalence and average depth has not been described

in the literature. The purpose of this study is to determine the

prevalence of an anterosuperior sublabral recess on MR

arthrography and the range of depths of the recess. Further char-

acterization of this normal anterosuperior labral variant may help

differentiate it from a labral tear on MR arthrography.

Methods and Materials: This study was approved by our institutional

review board. A retrospective review was performed on 104 con-

secutive patients who had undergone MR arthrography and sub-

sequent arthroscopy of the shoulder. The MR arthrograms were

reviewed in a blinded fashion by a MSK radiologist. The labrum

was divided into 8 segments and the anterosuperior segment was

classified as normal, torn, sublabral recess, sublabral foramen, or

Buford complex Patients who had undergone prior labral repair or

had fraying or tearing involving the anterosuperior labrum at ar-

throscopy were excluded, which left 59 patients in the final anal-

ysis. The presence of an anterosuperior labral variant was diag-

nosed if it was documented in the operative report or visible on

arthroscopic images, or was seen on MR arthrography and con-

firmed by a 2

MSK radiologist. The prevalence of an

anterosuperior sublabral foramen, anterosuperior sublabral recess,

and Buford complex was calculated. The average and range of the

anterosuperior sublabral recess was calculated.

Results: Thirteen out of 59 patients (22%) had an anterosuperior

sublabral recess, and all were seen at MR arthrography. Eleven out of

59 patients (19%) had an anterosuperior sublabral foramen, and 10/11

were seen at MR arthrography. Zero patients had a Buford complex. The

average depth of the anterosuperior sublabral recess was 2.8 mm. The

rangewas0.8to4mm.

Conclusion: The anterosuperior sublabral recess is a relatively common

but less described anatomic variant of the anterosuperior labrum,

occurring with greater frequency than an anterosuperior sublabral

foramen in this study. Recognition of the anterosuperior sublabral

recess as a normal variant on MR arthrography may help prevent

overestimating the length of Bankart and Superior Labrum

Anterior to Posterior (SLAP) tears.

Skeletal Radiol (2017) 46:845–871 865

Incidence of Rotator Internal Abnormality in 50 Consecutive

Shoulder MR Studies

N. Purohit

,A.Saifuddin

;

Stanmore/UK,

Middlesex/UK

Purpose: The rotator interval is a triangular space at the anterosuperior

aspect of the glenohumeral joint. It is bounded by the supraspinatus mus-

cle and tendon superiorly, the subscapularis muscle and tendon inferiorly

and the coracoid process at its medial base. The rotator interval contains

the coracohumeral ligament, the middle glenohumeral ligament, the su-

perior glenohumeral ligament, the long head of biceps tendon and the

anterior joint capsule.

Adhesive capsulitis (AC) or “frozen shoulder”is an inflammatory condi-

tion of the glenohumeral joint synovium and capsule leading to pain and

restriction in movement. Thought to be self-limiting, AC progresses

through several phases. Abnormality on MRI within the rotator interval

is commonly seen in cases of AC. These include thickening of the CHL,

obliteration of the normal fat signal surrounding the extracapsular portion

of the CHL as well as thickening of the axillary recess capsule-synovium.

We believe abnormality within the rotator internal is not an uncommon

finding on MRI performed for a number of shoulder pathologies.

Methods and Materials: We prospectively reviewed the presence of RI

and axillary recess capsule abnormality in 50 consecutive non-

arthrographic MRI studies of the shoulder reported by the lead author.

These studies were performed for numerous indications including adhe-

sive capsulitis.

Results: 50 consecutive MRI studies of 49 patients were reviewed: males

28, females 21. The average age was 32 years (range 21-80 years). The

most common indications for MRI was supraspinatus tendon tear (16/50),

pain unknown cause (9/50) and subacromial impingement (6/50). MRI was

performed in only 4/50 cases of suspected adhesive capsulitis.

Abnormality of the rotated interval was identified in 39/50 studies (78%).

The CHL specifically was abnormal in 36/50 studies. One of the cases of

clinically suspected adhesive capsulitis (1/4) had a normal MRI study.

There was no strong trend between clinical indication and incidence of RI

pathology.

Conclusion: Rotator interval abnormality on MRI is not an uncommon

finding which may often be over looked. It is sometimes assumed that

abnormality seen on MRI in this region is suggestive of an underlying

diagnosis of adhesive capsulitis. However we have shown from this co-

hort of 50 consecutive MRI studies that changes within the RI can be

associated with numerous pathologies and is not specific to adhesive

capsulitis.

Localization of the CT scanner - does it always has to be integrated in

the trauma room?

K.-F. Kreitner, P. Mildenberger, C. Lott, S. Kuhn; Mainz/DE

Purpose: A close distance of the CT scanner to the trauma room has a

significant positive effect on the probability of survival of severely injured

patients. However, due to edificial condtions and other reasons, some-

times an implementation of an high-end scanner into the trauma room is

not made or possible. In these cases, an alternative way for patient care

may be to equip a CTunit in this way that it can be used as a trauma room

for the supply of severely injured patients.

Methods and Materials: First, a multidisciplinary shockroom protocol

was established, with anaesthesiology, traumatic surgery, and radiology

being the core disciplines in the acute care of polytraumatized patients after

admittance in the hospital. According to this protocol, there was a strict

triage of severely injured patients: hemodynamically stable or latent stable

patients were transferred to the CT unit, whereas hemodynamically unstable

patients underwent an emergeny operation after primary survey. For assess-

ment of process quality, GCS and ISS scores, time between arrival and end

of whole body CT, patient outcome (lethality, duration of stay in hospital,

etc.) were recorded and sent to the German Trauma Register which is under

the surveillance of the German Society of Traumatologic Surgery.

Results: In the year 2014, the mean ISS score of severly injured patients

was 25.0, and thus higher than that of the nation-wide population (mean

18.4). Mean time for transportation of the patient to the CT unit was 1 minte

and 40 seconds. Mean time interval between arrival of the patients and end

of whoel body CT was 17 +/- 13 minutes. Patients had an lethality of 15.3

%, but this was significantly lower in comparison with that calculated on

the basis of injury severity of 18.5 %. In other words, outcome of patients

was better with regard to injury severity based on the nation-wide data

Conclusion: The use of a CT unit with appropriate room facilities and

equipment as a temporary shockroom may be an alternative to standard

recommendations in cases where edificial constraints do not allow an

implementation of a high-end CT scanner in the trauma room.

However, basic requirement for its successful use is the consequent

adherance to the multidiciplinary shockroom protocol and repeated train-

ing of all personnel involved in the care of polytraumatized patients.

Dark-Field Radiography in a clinical setting: new imaging technique

makes wooden foreign bodies visible

E. Braig

,L.Birnbacher

,F.Schaff

,L.Gromann

, A. A. Fingerle

,J.

Herzen

,E.J.Rummeny

, F. Pfeiffer

,P.B.Noel

,D. Muenzel

;

Garching/DE,

Munich/DE

Purpose: To investigate the potential of X-ray Dark-Field radiography

for the detection of wooden foreign bodies in plain radiographs.

Methods and Materials: Dark-Field imaging is a recently discovered

novel x-ray imaging method, which is based on the wave interaction of x-

rays with the sample, instead of conventional attenuation. It has originally

been developed at synchrotron sources, and more recently been trans-

ferred to clinically compatible setups. Using a specific arrangement of

x-ray transmission grids, the dark-field image and conventional attenua-

tion image can both be visualized with the image information derived

from a single radiograph examination using a standard clinical X-ray

machine. Beside the information on the attenuation of different tissues

in standard x-ray procedures, dark-field imaging provides additional in-

formation concerning the scattering of the X-ray beam. This is interesting

for porous structures, as they lead to a high level of scattering, and there-

fore presentwith a high signal in dark-field imaging. To evaluate potential

future clinical applications of dark-field imaging, we investigated in this

work, the dark-field signal of wooden foreign bodies in a model with

splinters of different sizes (diameter 0.1 to 1.1 mm). In addition, a spec-

imen with iatrogen implemented wooden fragments (diameter 1.1 mm,

length 2.2 cm and 3.7 cm) was examined, and the signal-to-noise ratio

(SNR) was calculated. All experiments were performed using a standard

clinical X-ray tube.

Results: In the phantom experiment, all wooden fragments were clearly

detectable in dark-field images down to a diameter of 0.1 mm. In conven-

tional attenuation imaging, only the wooden fragments with a large diam-

eter of 1.1 mm and 0.9 mm were visible. The mean SNR was 6.0 in the

absorption images and 19.4 in the dark-field images. The attenuation im-

ages of the specimen hand did not reveal the wooden fragments. However,

both wooden fragments were clearly visualized in the dark-field image.

Conclusion: Dark-field radiography allows for a substantial improve-

ment of the detectability of wooden foreign bodies compared to standard

radiography.

866 Skeletal Radiol (2017) 46:845–871

Saturday, June 17

Scientific Paper Session - Ankle and other

Posterior tibial tendon dysfunction: Correlation between magnetic

resonance imaging, clinical and histological findings

V. Chianca

,D.Albano

, N. Martinelli

, A. Bianchi

,M.Midiri

,L.M.

Sconfienza

;

Naples/IT,

Palermo/IT,

Milan/IT

Purpose: To investigate the correlation between Magnetic Resonance

Imaging (MRI), clinical tests and histopathologic features of posterior

tibial tendon (PTT) dysfunction in patients with acquired adult flatfoot

deformity (AAFD), surgically treated with medializing calcaneal

osteotomy and flexor digitorum longus tendon (FDLT) transposition.

Methods and Materials: Twenty-seven patients (17 females; age: 46

±15, range 18-75) with PTT dysfunction and AAFD, unresponsive to at

least six months of conservative treatments, were surgically treated using

medializing calcaneal osteotomy and FDLT transposition technique.

Before surgery, all patients performed the single heel rise (HR) and first

metatarsal rise sign (FMR) tests; among them, 20 performed the MRI

scan of the ankle up to one month before surgery. After surgery, the

specimens of the removed PPTs were histologically analysed by two

different anatomo-pathologists using the Bonar and Movin scores. A

radiologist and a radiology resident independently reviewed the MRI

scans. They graded the PTT tears on a I-III scale and measured the

MRI hindfoot valgus angle. A Spearman’s rank-order correlation was

run to determine the relationship between the variables. A P-value lower

than 0.05 was considered as statistically significant.

Results: The severity of hindfoot valgus angle was not statistically cor-

related to that of PTT tendinopathy (P=0.246). The correlation between

clinical tests was at limit of significance (P=0.051). The MRI grade of

tendinopathy was significantly correlated to FMR (P=0.011) but not to

HR test (P=0.768); conversely, the hindfoot valgus angle was not signif-

icantly correlated to the FMR (P=0.099) but even it was not correlated to

the HR test (P=0.597). The histological tests showed the highest correla-

tion among the different variables investigated (P<0.001). The HR and

FMR tests were significantly correlated to the Movin score (P=0.009 and

P=0.018, respectively) and were almost statistically correlated to the

Bonar score (both with a P=0.070). Conversely, the MRI parameters

did not show a significant correlation to the histological tests.

Conclusion: Our study reveals a high correlation between the clinical

tests and the histological features of PTT dysfunction. The FMR and

HR tests are highly reliable in identifying PTT degenerative changes.

Conversely, neither the hindfoot valgus angle nor the morphological

and signal changes of PTTevaluated with MRI seem to allow for a correct

assessment of the degree of PTT degenerative changes. Nevertheless,

MRI remains a useful tool to confirm the clinical evidence of PTT dys-

function and to provide a preoperative assessment of bony and soft tissue

structures.

Evaluation of reproducibility of the MOCART score in patients with

osteochondral lesions of the talus repaired using the autologous

matrix-induced chondrogenesis (AMIC) technique

A. Corazza

,D.Albano

, N. Martinelli

,A.Bianchi

,A.Zerbi

,L.M.

Sconfienza

;

Genoa/IT,

Palermo/IT,

Milan/IT

Purpose: To evaluate the applicability and reproducibility of the

Magnetic Resonance Observation of Cartilage Repair Tissue

(MOCART) score for morphological evaluation of osteochondral lesions

of the talus (OLT) repaired using the autologous matrix-induced chondro-

genesis (AMIC) technique.

Methods and Materials: Two radiologists (R1-R2) and two orthopaedic

surgeons (O1-O2) independently reviewed 26 MRI scans of the ankle

performed on 13 patients (6 females, 7 males; age: 38.9±15.9, range

14-63) with OLT repaired using the AMIC technique between

November 2011 and July 2015 at our institution. Out of 13, 7 were treated

with biomimetic osteochondral scaffold implantation, while 6 were treat-

ed with bone-marrow derived cell transplantation.The MRI scans were

performed at 6 and 12 months after treatment. For inter- and intra-

observer agreement evaluation for each variable of the MOCART score

we used Cohen’s kappa coefficient. Progression of MOCART score be-

tween 6 and 12 months evaluation was assessed using the Wilcoxon test.

Results: The inter-observer agreement between R1-R2 ranged from poor

(adhesions, k=0.124) to almost perfect (subchondral bone, k=0.866),

while between O1-O2 ranged from absent (effusion, k=-0.190) to poor

(surface,k=0.172). The intra-observer agreement of R1 ranged from poor

(signal intensity, k=0.031) to substantial (subchondral lamina, k=0.677),

while that of O1 ranged from absent (subchondral bone, k=-0.061) to

substantial (surface, k=0.663). There was a statistically significant in-

crease of MOCART score between 6-month and 12-month evaluation

of R1 (Z=-2.672; P=0.008), R2 (Z=-2.721; P=0.007) and O1 (Z=-

3.034; P=0.002). Conversely, the increase of MOCART score between

the 6-months and 12-months evaluation of O2 was not statistically sig-

nificant (Z=-1.665; P=0.096).

Conclusion: MRI certainly has a crucial role in the follow-up of surgical

repaired OLT but the MOCART score does not seem to be sufficiently

reliable and reproducible to be applied for this purpose.

Magnetic Resonance and Ultrasound in Achilles tendinopathy:

Predictive role and response assessment to platelet-rich plasma and

adipose-derived stromal vascular fraction injection

C. Messina

, D. Albano

,A.Poloni

, C. Maccario

,F.G.Usuelli

,L.M.

Sconfienza

;

Milan/IT,

Palermo/IT,

Arcene/IT

Purpose: To assess the correlation between magnetic resonance and ul-

trasound findings and clinical outcome after intratendinous injection of

leucocyte-rich platelet-rich plasma or adipose-derived stromal vascular

fraction in patients with non-insertional Achilles tendinopathy.

Methods and Materials: Forty-three patients (age: 47.8±5.1, range 29-

55) with unilateral or bilateral non-insertional Achilles tendinopathy (58

tendons overall) were randomly assigned to platelet-rich plasma (22 pa-

tients, 28 tendons) or adipose-derived stromal vascular fraction (21 pa-

tients, 30 tendons) injection group. All patients underwent magnetic res-

onance (tendon cross-sectional area, signal intensity, maximum

anteroposterior thickness were measured), ultrasound (maximum

anteroposterior thickness, power Doppler signal, ultrasound gray scale

echotexture were measured), and visual analogue scale pain evaluation

at baseline and at six months from treatment. Wilcoxon, intraclass corre-

lation coefficient, repeated measure ANOVA tests were used.

Results: There was a significant (P<0.001) decrease of mean VAS from

pre-treatment (6.4±1.4) to six-month evaluation (1.8±1.7). Significant

increase of tendon thickness measured using magnetic resonance

(P=0.013) and ultrasound (P=0.012) and power Doppler signal

(P=0.027) was seen. There was no significant difference between pre-

and post-treatment cross sectional area, signal intensity, and echotexture

(P>0.217). None of the pre-treatment parameters was a predictor of treat-

ment outcome (P>0.104). There was an excellent agreement between

tendon thickness measurement between magnetic resonance and ultra-

sound (intraclass correlation coefficient=0.986)

Skeletal Radiol (2017) 46:845–871 867

Conclusion: Both treatments seem to allow for clinical benefit, associat-

ed to early slight increase of tendon size and power Doppler signal.

Imaging cannot be used as a predictor of clinical outcome.

Plantar plate disease as a part of forefoot overload syndrome: the

role of MRI in detecting associated injuries

V. Te m p e s t a

, C. Ottonello

,A.Giardino

,P.Giuliani

, F. Martinelli

;

Viterbo/IT,

Pomezia/IT,

Rome/IT,

Lissone/IT

Purpose: Aim of our study is to evaluate the role of MRI in detecting

plantar plate disease (PPD) associated forefoot diseases, assuming that

PPD is probably only a component of a forefoot chronic overload

syndrome.

Methods and Materials: We retrospectively revalued the MRI (S-Scan

sectorial MR unit, Esaote, Genova-Italy) of 39 patients (12 males, 27

females, age 27-82, mean 51,1 ± 14,6 sd) with diagnosed PPD (com-

plete/partial tear), performed from June 2015 to September 2015, by

using a standard protocol (T1 and T2 fat suppressed coronal slices, T2

axial slices and T2 sagittal, basal and with stress test slices).

Results: PPD was found at second metatarsophalangeal joint (MF) in

3/39 (7,7%), at second-third MF in 27/39 (69,2%) patients, at second-

third-fourth MF in 9/39 (23,1%). In 6/39 (15,4%) was observed

intermetatarsal space (IS) neuroma, in 6/39 (15,4%) second IS wide

pericapsular fibrosis, in 6/39 (15,4%) second and third MF bursitis. In

9/39 (30,8%) were found bone lesions (1/39 second metatarsal Freiberg

disease, 1/39 fifth metatarsal head stress fracture, 7/39 first MF degener-

ative arthritis) and in 12/39 (30,8%) flexor tendinopathy.

Conclusion: In our study PPD is frequently associated (27/39, 69,2%)

with other forefoot diseases, all reliably related to microtraumatic chronic

pathogenesis and therefore may be thought as a part of a chronic overload

syndrome; in particular the frequence of bone involvement (30,8%) nec-

essarily requires MRI evaluation in order to perform an exhaustive early

diagnosis.

Quantitative assessment of joint space narrowing progression in the

feet of rheumatoid arthritis patients using a computer-based tempo-

ral subtraction method

H. Chiba, T. Kamishima, S. Ichikawa, T. Okino, J. Fukae, Y. Aoki, K.

Tanimura; Sapporo/JP

Purpose: In the assessment of joint space width using conventional radi-

ography in patients with rheumatoid arthritis (RA), computer-based

methods have been developed to overcome the disadvantages of conven-

tional methods which depend on subjective visual assessment. However,

these computer-based methods exclusively target on the hand, although feet

are a predilection site for rheumatoid involvement. We therefore attempted

to validate our computer-based method on the feet of RA patients.

Methods and Materials: The study consisted of 19 patients with RA

who underwent radiography of the feet at baseline and at 24 weeks fol-

low-up. Joint space narrowing (JSN) of the interphalangeal (IP) joint of

the big toe and metatarsophalangeal (MTP) joints of the 1

to 5

toes on

radiographs were assessed by our computer-based method, using the

Genant-modified Sharp scoring method as a standard of reference. We

defined the JSN progression index (JSNPI) as quantitative value for in-

terval change in JSN derived from our computer-based method using a

temporal subtraction technique.

Results: 211 out of 228 toe joints were successfully analyzed; 17 joints

were eliminated because of subluxation or ankylosis. The JSNPI of joints

with JSN progression (n = 14) was significantly higher than that without

JSN progression (n = 197) (Mann-Whitney U test, P<0.0001). Among

joints without JSN progression, there was no statistically significant dif-

ference in the JSNPI between the left and right joints (Mann-Whitney U

test, P>0.05) and between 1-5 toe joints (Kruskal-Wallis test, P>0.05).

Conclusion: Our computer-based method may be useful to recognize the

JSN progression of the toe joints on radiographs of the feet of RA pa-

tients.

Efficacy of US-guided needling for the treatment of Achilles tendon

tendinopathy: clinical and imaging evaluation in comparison with

conservative physical therapy

S. Quarchioni, F. Bruno, F. Arrigoni, S. Mariani, L. Zugaro, A. Barile, C.

Masciocchi; L'Aquila/IT

Purpose: To determine the effectiveness of ultrasound guided percutane-

ous needle tenotomy in terms of clinical improvement and morphological

recovery in patients with tendinopathy of the Achilles tendon, compared

to conservative therapy.

Methods and Materials: We included in the study 50 patients (27 men,

23 women, mean age 38.4 years) with Achilles tendon tendinopathy. The

patients underwent MRI and ultrasound examination following referral

with clinical diagnosis of tendinosis (mean symptom duration 3 months).

Pre- and post-procedure (at 6 months follow-up) VAS and VISA-A scores

were collected to assess patient clinical response. 25 patients (GROUP A)

were treated with sonographically guided percutaneous needle tenotomy,

25 patients (GROUP B) were submitted to conservative therapy.

Instrumental follow up with ultrasound and MRI examination was per-

formed before and 6 months after the treatment to evaluate tendon

morphology.

Results: The study group (needling) showed recovery of tendon

echogenicity and MRI signal intensity in 18 patients (72%), 5 patients

(20%) showed no improvement and 2 patients (8%) showed worsening of

the tendinopathy. Mean VAS scores were significantly lower at the

follow-up (2.2± 0.7) compared with the baseline (5.8 ± 0.6) in 20 patients

(80%); 5 patients (20%) had no improvement. The mean VISA-A values

improvement was 67%. In the control group we noted recovery of tendon

echogenicity and MRI signal intensity in 7 patients (28%), 14 patient

(56%) showed no improvement and 4 patients (16%) showed worsening

of the tendinopathy. 56% of the patients showed improvement in VAS

and 48% in VISA-A values.

Conclusion: US-guided dry needling guidance shows promise as a

cheap, safe and effective minimally invasive treatment for patients with

tendinosis of the Achilles tendon.

Value of weight-bearing (WB) MRI scans for the evaluation of trau-

matic and overload pathologies of the midtalar (MT) and subtalar

(ST) joints

F. Bruno, S. Quarchioni, S. Mariani, F. Arrigoni, A. Barile, C.

Masciocchi; L'Aquila/IT

Purpose: To evaluate the possible biomechanical modifications of the

ankle and foot during upright-MRI in patients with traumatic and over-

load pathologies of the MT and ST joints.

868 Skeletal Radiol (2017) 46:845–871

Methods and Materials: We selected 48 patients clinically suspected for

MT and ST pathology. MRI examinations were performed with a dedi-

cated 0.25 T scanner, in supine and WB position. We obtained axial,

sagittal and coronal SE T1W sequences and we measured the talo-

calcaneal angle, the lateral talocalcaneal angle and the Costa-Bertani

angle.

Results: Standard MRI showed 72 pathological findings in 48 patients: in

3 cases a spring ligament (SL) involvement, in 8 a sinus tarsi ligaments

(STL) involvement, in 21 a posterior tibialis tendon (PTT) involment, in

40 cases a chondropathy (talonavicular in 6, calcaneus-cuboid in 3 and

sinus tarsi in 31). Talo-calcaneal angle was abnormal in 32% ofthe cases,

lateral talocalcaneal angle in 38% and Costa-Bertani angle in 30%. In the

upright-MRI scans we found modifications of the talo-calcaneal angle

(55%), the Costa-Bertani angle (47%) and the lateral talocalcaneal angle

(58%) with a tendency to an hindfoot valgus; as direct consequence of

these modifications we noted an increase of the involvement of the SL (7

cases) and the STL (11 cases). Tendinophaties and condrophaties didn’t

have significant modifications.

Conclusion: MRI is the gold-standard to identify ligamentous structures

of the ankle and WB-MRI, under physiological load, gives us additional

and correct information on possible modifications of these structures and

of the sinus tarsi and “coxa pedis”alignment.

MR finding of Deltoid ligament tear: Which component of the deltoid

ligament was injury-prone?

Y. Kobashi

, Y. Munetomo

,A.Baba

, S. Yamazoe

,T.Mogami

;

Chiba/

JP,

Ichikawa/JP,

Tokyo/JP

Purpose: To know which component of the deltoid ligament is injury-

prone.

To know how often deltoid ligament tear is detected in patients with

anterior talofibular ligament.

Methods and Materials: We selected 60 patients for our study. All of the

patients were diagnosed with an acute or chronic anterior talofibular lig-

ament (ATFL) tear in both a physical examination and ankle MRI.

Patients with malleolar fracture were excluded. We categorized these

patients into 2 groups: Deltoid group and ATFL group.

The Deltoid group consisted of twenty-five of the 60 patients, who were

diagnosed with both deltoid ligament tear and ATFL tear. The ATFL

group consisted of thirty-five of the 60 patients who had the ATFL tear

without the deltoid ligament tear. First, we checked which component of

the deltoid ligament was injury-prone using the Deltoid group on MRI.

Second, we investigated the deltoid ligament tear in the ATFL group.

Third, we investigated distributions of bone marrow edema.

Results: In Deltoid group, all of the 25 patients got an injury of anterior

tibiotalar ligament (ATTL). Eleven of the 25 patients had the ATTL tear,

and had 1 or 2 anterior components tear of the deltoid ligament, such as

tibionavicular ligament tear and/or tibiospring ligament tear. Thirteen of

the 25 patients had posterior tibiotaler ligament (PTTL) tear.

In ATFL group, six of the 35 patients had deltoid ligament tear. All of the

6 patients had ATTL tear and/or anterior components tear. However, none

of the 6 patients had PTTL tear or posterior component tear, such as

tibiocalcaneal ligament tear. Nineteen ofthe 60 patients had bonemarrow

edema. Eleven of the 60 patients had the bone marrow edema in medial

talus which is attachment of the ATTL. Four of the 60 patients had the

bone marrow edema in medial malleolus.

Conclusion: Deltoid ligament has five components. The ATTL was a

small ligament and was present in the narrow space between medial

malleolus and talus. A strong external rotation to foot may directly hurt

the ATTL as compared to the other component as long as patients have no

malleolar fracture. Regarding to the patients who are diagnosed with only

ATFL tear like the ATFL group, we need to rule out the ATTL tear more

carefully. In addition, from distribution of the bone marrow edema, the

ATTL in the attachment of the talus seemed to be weak against the exter-

nal rotation force as compared to the attachment of the medial talus.

Quantitative muscle ultrasound as an imaging biomarker for frailty

syndrome

R. Mirón Mombiela, J. Vucetic, P. Monllor, F. García, F. Facal de Castro,

C. Borrás; Valencia/ES

Purpose: Many anatomical structures, like muscle, have repeating sub-

units and therefore fractal properties. It is theorized that progressive loss

of complexity in the fractal architecture of muscle can characterize both

aging and frailty.

The primary objective was to compare Echo Intensity (EI) to muscle

fractal analysis as a more accurate imaging biomarker for frailty

syndrome.

The secondary objective was to determine if fractal analysis of muscle

structure by ultrasound is correlated with decreased muscle strength and

frailty in the elderly.

Methods and Materials: A cross sectional study was performed with

subjects under 60 years old who participated as controls, and 60 years old

or older who participated in the experimental group. This latter group was

subdivided into robust, pre-frail and frail individuals, according to the

frailty criteria. The anterior compartment of the thigh was measured by

B-mode ultrasound obtaining cross-sectional images. EI values were ob-

tained using the Image-J software. A ROI of the muscle was selected and

the histogram function was applied. For the muscle fractal analysis we

used the service of QUIBIM, an imaging biomarker company. The US

studies was processed using 2D box-counting techniques where the frac-

tal dimension parameter (D

) and pixel intensity (PI) were calculated.

The muscle strength values were measured using a hand dynamometer.

The statistical analysis was performed with SPSS software.

Results: A total of 48 subjects were included in the study (12 subjects in

each group). EI, D

and PI showed a negative correlation with muscle

strength (EI: r = -0.236, p >0.05; D

: r = -0.428; p <0.01 and PI: -0.292;

p <0.05) and apositive with frailty(EI: r = 0.439, p <0.01; D

:r=0.109;

p >0.05 and PI: 0.515; p <0.01). A similar trend was acknowledged for

muscle thickness and quality of life. The data also showed statistical

differences between EI, PI and muscle strength in the different stages of

frailty (p <0.05), but not for D

Conclusion: Our latest results suggest a relevant influence between frac-

tal analysis and muscle strength in the context of the frailty syndrome and

the possible use of PI as an imaging biomarker for its identification. These

results also suggest that fractal analysis is a better method to analyse

muscle changes in ultrasound than EI.

Characterising changes in muscle quantity and quality in patients

requiring extracorporeal membrane oxygenation (ECMO) during

critical illness: an observational cohort study

A. Isaac, D. Dalili, B. Connolly, L. Allum, Danielle Bear, Stavros

Dimopoulos, N. Hart, N. A. Barrett; London/UK

Purpose: Primary Objective:

To characterise sequential changes in parameters of muscle architecture

and quality of the transverse abdominis, quadriceps rectus femoris, and

Skeletal Radiol (2017) 46:845–871 869

tibialis anterior muscles in critically ill patients requiring ECMO across

Days 1, 3, 7, and 10 of ICU admission.

Secondary Objectives:

To determine if muscle changes are related to levels of physical activity.

Methods and Materials: 40 eligible patients underwent ultrasound as-

sessment of muscle architecture and quality on Days 1, 3, 7 and 10 of

commencing ECMO therapy. All other clinical management remained

unchanged. Inclusion and exclusion criterias were defined.

Outcome measures:

Primary:

Change in parameters of muscle architecture and quality of the rectus

abdominis, transverse abdominis, quadriceps rectus femoris, and tibialis

anterior muscles.

Secondary:

Effects of changes in the physical activity levels:

Physical activity monitoring: On Days 1-10 of ICU admission patients wore

an activity monitor (Sensewear MF Armband), which uses several inertial

motion sensors to track the movement and acceleration of the limbs in

horizontal and vertical directions. They can measure inactivity, activity, step

counts and metabolic equivalent (METS). In addition the Sensewear mea-

sures energy expenditure and sleep duration. These physical activity mon-

itors have been used widely in previous research studies in intensive care.

Patients also underwent daily assessment of global peripheral skeletal

muscle strength assessed by the Medical Research Council Sum-score

(part of routine physiotherapy assessment, 5-10 minutes) and global func-

tion measured by the Chelsea Critical Care Physical Assessment Scale

(part of routine physiotherapy assessment, 10-15 minutes).

Additional data collection included clinical (e.g. ICU admission diagno-

sis, illness severity, duration ICU length of stay prior to enrolment, co-

morbidities, nutritional management, duration of mechanical ventilation,

pharmacotherapy); demographic (e.g. age, gender); and therapy.

Results: There were statistically significant changes in muscle volume,

echogenicity, architecture and outline over time.

Conclusion: These findings may have functional implications for survi-

vors of critical illness in ECMO patients, and may have an impact on the

duration and quality of physiotherapy and rehabilitation offered to survi-

vors. Understanding these changes enables the clinical team to monitor

and treat the patients, with the aim of improving the short and long-term

outcomes following ICU discharge.

There are currently validated studies correlating the incidence and rate of

the aforementioned muscle changes with the overall prognosis, including

the morbidity and mortality of ICU patients.

Recognising (and evaluating) the musculoskeletal impact of critical ill-

ness on ECMO patients, as a specific subset of this cohort is therefore

pivotal to tailoring patient care.

Measurement of pennation angle in the aging population

J. Vucetic, R. Mirón Mombiela, P. Monllor, F. Facal de Castro, C. Borrás;

Valencia/ES

Purpose: Pennate muscles (most of locomotor muscles) are those with

the fibers running at an angle to the muscle´s line of action. Loss of

muscle mass and, consequently, of muscle strength, is an important fea-

ture of aging.

The purpose of this study was to evaluate if pennation angle (PA) obtain-

ed by ultrasound is an accurate imaging biomarker for changes in muscle

architecture with aging. Also, we wanted to determine if there was an

association between PA and decreased muscle strength (MS), muscle

thickness (MT), echo intensity (EI) and frailty in the elderly individuals.

Methods and Materials: A retrospective cross-sectional study was per-

formed with total of 108 subjects, ranging from 20 to 90 years of age.

Subjects from 20 to 59 years old participated as controls. Subjects aged 60

and older participated in the experimental group. This latter group was

subdivided into robust, pre-frail and frail individuals, according to the

Fried’s frailty criteria. The ultrasound images of the anterior compartment

of the thigh were obtained with subjects in supine position with extended

leg. The PA, EI and MT were recorded. PA was obtained measuring the

angle between the deep aponeurosis and pennate fascicles of rectus

femoris using the angle tool from the Image-J software. The MS values

were measured with a hand dynamometer. SPSS software was used for

statistical analysis.

Results: PA was negatively correlated with age (r=-0.417; p<0.01) and

frailty index (r=-0.400; p<0.01), both parameters showing moderate cor-

relations. A moderate positive correlation was found between PA and MT

(r=0.518; p<0.01) while PA and MS showed weak positive correlation

(r=0.297; p<0.002). The data also showed statistical differences of pen-

nate angles between controls and different stages of frailty (p<0.01).

Conclusion: The current results suggest that pennation angle could be an

useful imaging biomarker not only for decreased muscle mass and chang-

es in muscle architecture in the elderly population, but for frailty syn-

drome as well. These preliminary results open a new field of research to

determine whether this parameter could be useful per se as a marker of

aging and frailty.

Paleoradiological analysis of mummifed parts from Egyptian

Collection of Zagreb Archeological Museum

M. Cavka

,D.Štivić

,H.Cvija

,A.Petaros

;

Zagreb/HR,

Fieberbrunn/

AT,

Rijeka/HR

Purpose: The purpose was to analyze and compare images of mummi-

fied body parts dated to Ancient Egypt gained by standard

paleoradiological tools (X-ray and CT) with those gained by MR and

micro CT, techniques which have till now been rarely used in the scien-

tific study of mummies.

Methods and Materials: Four hands and two feet were scanned in LL

and AP direction at the University Hospital "Dubrava" on X-ray unit

(RAD Speed, Shimadzu, Europa GmbH, Duisburg, Germany).

Transverse CT slices were obtained using 16 x 0.75 collimation and

images were reconstructed at 0.75-mm section thickness and 0.7 mm

reconstruction increment (RI) using a MDCT unit (Sensation 16;

Siemens Healthcare, Erlangen, Germany). 3-dimensional (3D), spoiled

gradient echo based UTE images of the specimen were acquired on a 1.5-

T scanner (Magnetom Avanto, Siemens Healthcare, Erlangen, Germany)

employing manufacturer’s head coil, contrast-determining parameters

echo time, repetition time and flip angle were chosen 0.07 ms, 15 ms

and 45°, respectively. The 40000 radial projec