Multimodal Imaging in the Comprehensive Evaluation of Kohler Disease: A Case Report and Literature Review.

To assess the association between clinical features and magnetic resonance imaging (MRI) findings in posterior ankle impingement syndrome (PAIS) and to compare the prevalence of imaging findings between participants with and without a clinical diagnosis of PAIS. Case-control study. Elite ballet and sport. Eighty-two male (54%) and female participants comprising ballet dancers (n = 43), cricket fast bowlers (n = 24), and football (soccer) players (n = 15). Clinical: posterior ankle pain on body chart, passive plantarflexion pain provocation test. Patient-reported outcome measures: Oslo Sports Trauma Research Center Overuse Injury Questionnaire, Foot and Ankle Ability Measure Sports subscale. Imaging findings including posterior ankle bone marrow edema, os trigonum (± bone marrow edema, and increased signal at synchondrosis), Stieda process (± bone marrow edema), talocrural and subtalar joint effusion-synovitis size, flexor hallucis longus tendinopathy, and tenosynovitis identified as present or absent on 3.0-Tesla MRI. Imaging findings were not associated with posterior ankle pain or a positive ankle plantarflexion pain provocation test. Imaging findings were not associated with patient-reported outcome measures. Imaging findings did not differ between PAIS-positive and PAIS-negative groups. Os trigonum and Stieda process were prevalent despite clinical status. The lack of association between imaging findings and clinical features questions the role of imaging in PAIS. Clinicians should rely primarily on clinical assessment in the diagnosis and management of patients with PAIS.

Background: To analyze long-term ophthalmic clinical and multimodal imaging findings of disseminated Mycobacterium (M.) chimaera infection after cardiothoracic surgery among the Swiss Cohort. Methods: Systemic and multimodal ophthalmic imaging and clinical findings including rate of recurrence were reviewed and correlated to a previously proposed classification system of choroidal lesions and classification of ocular disease. Main Outcomes Measures: long-term clinical and multimodal ocular imaging findings of M. chimaera. Results: Twelve patients suffering from systemic infection from M. chimaera were included. Mean age at the first ophthalmic examination was 59 years (range from 48 to 66 years). Mean duration of the follow-up was 22.63 ± 17.8 months. All patients presented with bilateral chorioretinal lesions at baseline; 5 patients had additional signs, including optic disc swelling (2), choroidal neovascularization (1), retinal neovascularization (1) and cilioretinal vascular occlusion (1). Four recurrence events after discontinuation or adjustment of the antibiotic treatment were observed. Progressive choroiditis was seen in 5 patients under treatment, 4 of them deceased. Conclusions: Expertise from ophthalmologists is not only relevant but also critical for the assessment of the adverse drug effect of antimycobacterial treatment along with monitoring therapeutic response and identifying recurrences.

<p>Spondyloarthritis (SpA) describes a group of related inflammatory conditions, including ankylosing spondylitis (AS), psoriatic arthritis, reactive arthritis, SpA associated with inflammatory bowel disease and undifferentiated SpA.1 Classification criteria have been developed and validated by the Assessment of SpondyloArthritis international Society (ASAS) to distinguish axial‐predominant SpA from peripherally predominant SpA. These criteria contribute to diagnosis, but are not ideal diagnostic criteria as they possess only moderate sensitivity. Diagnosis of axial SpA should be established by a rheumatologist, after careful consideration of these criteria and individual patient factors.</p><p>Recent research into axial SpA has improved diagnostic assessment, using MRI and has established MRI and radiography as the main tools for assessing disease activity, response to treatment and prognosis. Diagnosis of axial SpA is often dependent on the choice and interpretation of imaging in individuals with axial symptoms. These consensus statements were developed to provide an evidence‐based approach to imaging in axial SpA.</p>

BackgroundBipartite navicular bone is a relatively uncommon pathological condition, characterized by splitting of the navicular bone into two parts. Patients with this anomaly typically present with chronic pain at the dorsomedial aspect of their foot and a flatfoot deformity. This study aimed to describe the imaging findings related to the presence of this uncommon anatomical variant.ResultsMagnetic resonance imaging was done for all 24 patients with bilateral involvement in four patients, yielding 28 feet. On MRI, separation of the navicular bone with unequal size of the two fragments was observed in all examined feet and secondary talonavicular degenerative osteoarthrosis identified in 16 feet. Bone marrow edema was seen at the parent navicular bone in 10 feet, while the lateral fragment showed bone marrow edema in 18 feet. Ten patients, with bilateral involvement in four of them, yielding a total of 14 feet did MDCT studies which were reviewed. Separation of the navicular bone into two parts by oblique cleft with unequal size of the two fragments in all examined feet. Comma-shaped appearance of the main navicular bone with medial translation relative to the talar head was identified in 8 feet. Secondary talonavicular degenerative osteoarthrosis was observed in 10 feet. Plain X-ray of the symptomatic foot was reviewed in eight patients yielding a total number of 12 examined feet due to bilateral involvement in four patients. On AP view, the lateral bone fragment was obscured in all examined feet. On lateral view, an irregular bone separated from the dorsal aspect of the navicular bone was identified in 10 feet, while failure of identification of the cleft between the two fragments on the lateral view in 2 feet but was nicely demonstrated on oblique view. Irregularity in the talonavicular joint space was observed in 8 feet.ConclusionsBipartite navicular bone is rare anatomic variant that causes mid-foot pain and osteoarthritic changes around the navicular bone. In cases where pathology in relation of the presence of this anatomical variant is suspected, detailed clinical correlation and careful assessment with MRI and MDCT will play an important role.

Longitudinal multivoxel MR spectroscopy study of pediatric diffuse pontine gliomas treated by radiotherapy

We encountered five otherwise healthy adults with alterations of the tarsal navicular bone compatible with spontaneous osteonecrosis. Four women had bilateral involvement and one man had unilateral involvement. The patients were 23-71 years old. The disorder was initially described by Mueller and Weiss and should not be confused with Koehler disease (osteochondrosis of the tarsal navicular in children). This group of patients was compared with five other patients (29-74 years old) with similar radiographic and clinical changes in whom an underlying disease (rheumatoid arthritis, renal failure, trauma, and lupus erythematosus) associated with osteonecrosis was known. Routine radiography in both groups defined characteristic abnormalities of the navicular bone (decreased size, a comma-shaped configuration, increased radiodensity, fragmentation, and medial or medial and dorsal osseous protrusion). MR in three patients confirmed alterations consistent with osteonecrosis. Three of the patients without underlying disease had bilateral involvement on plain films, with flat feet and hindfoot valgus deformity, leading to local pain and deformity. In a fourth patient, bilateral distribution was documented by MR as marrow alterations. Although no certain pathogenic explanation for spontaneous osteonecrosis of the tarsal navicular is known, trauma and chronic stress changes caused by physiologic pressure on the medial longitudinal arch in hindfoot valgus and increased tension forces of the plantar aponeurosis during weight-bearing (in pes planus) may be important. Discrimination of primary from secondary osteonecrosis of the tarsal navicular bone is not possible by radiologic means alone, although bilateral distribution, particularly in women, favors the diagnosis of spontaneous disease.

To provide a novel MRI classification system for the symptomatic type II os naviculare by creating a standardized grading of associated bone marrow edema (BME) and correlating with patient symptoms. BME was classified on an ordinal scale: grade 1, faint signal immediately adjacent to the synchondrosis; grade 2, intermediate signal within the os and navicular tuberosity without extending to the navicular body; grade 3, intense signal extending to the navicular body. BME on 59 MRIs was independently graded by three radiologists. Inter- and intra-observer agreement was analyzed using intraclass correlation coefficient. Univariate and multivariate analyses assessed for patient and imaging characteristics predictive of subjective pain score. A cohort of 82 patients without BME represented a control group. Inter-observer agreement of BME grade was 0.95 (CI 0.93-0.97) and intra-observer was 0.92 (CI 0.87-0.96), indicating excellent agreement. In patients with BME, predictors of more severe pain were longer duration of pain (p = 0.02) and presence of soft tissue edema overlying the os naviculare (p < 0.001). One hundred percent of subjects with BME localized their pain to the medial midfoot (59/59) versus 25.6% (21/82) of controls (p < 0.001). This novel grading system provides reliable quantification of BME associated with os naviculare, which is a specific cause of medial foot/ankle pain. Early diagnosis is important as pain severity worsens with longer duration of symptoms. Pain severity is correlated with soft tissue edema overlying the os, which may be secondary to extrinsic compression, reactive to biomechanical stress, or reflect direct trauma.

Maternal circulating biomarkers associated with placenta accreta spectrum disorders.

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

Mueller-Weiss syndrome is a rare condition seen in adults due to spontaneous osteonecrosis of tarsal navicular bone unlike Koehler's disease which is quite common in paediatric population. We report a single case of Mueller-Weiss syndrome in an adult female. After a trail of conservative treatment, operative management was done with excision of necrotic fragment and arthrodesis of mid-foot joints augmented with tricortical iliac crest graft. Good fusion and significant reduction of pain on weight-bearing was observed after a duration of 6 weeks. Mueller-Weiss syndrome is relatively rare differential for mid-foot pain in adult population. Early recognition and management of the condition prevents arthritic changes and disability.

Clinical and Multimodal Imaging Findings in Disseminated Mycobacterium Chimaera

To prospectively evaluate the association between clinical features and structural abnormalities found at magnetic resonance (MR) imaging in patients with osteoarthritis (OA) of the knee. The study was approved by the institutional medical ethics review board. Written informed consent was obtained from each patient. MR images of the knee were obtained from 205 (42 [20%] men, 163 [80%] women; median age, 60 years; range, 43-77 years) patients in whom symptomatic OA at multiple joint sites was diagnosed. MR images were analyzed for various abnormalities of OA. All patients were interviewed concerning pain and stiffness in the knee that was imaged. Odds ratios (ORs) with 99% confidence intervals (CIs) were used to determine the association between the imaging findings and clinical features of OA. A large joint effusion was associated with pain (OR, 9.99; 99% CI: 1.28, 149) and stiffness (OR, 4.67; 99% CI: 1.26, 26.1). The presence of an osteophyte in the patellofemoral compartment (OR, 2.25; 99% CI: 1.06, 4.77) was associated with pain. All other imaging findings, including focal or diffuse cartilaginous abnormalities, subchondral cysts, bone marrow edema, subluxation of the meniscus, meniscal tears, or Baker cysts, were not associated with symptoms. Findings of this study indicate that only two associations exist between clinical symptoms and structural findings found on MR images in patients with OA of the knee.

Köhler's disease is a self-limiting disorder affecting endochondral ossification, marked by fragmentation and sclerosis in the tarsal navicular bone. In 1908, Köhler highlighted these complexities by describing concurrent osteochondrosis of the tarsal navicular. A relevant case involves a 5-year-old girl who visited an orthopedic clinic with bilateral foot pain and an inability to bear weight for a week. She was diagnosed with bilateral Köhler's disease. Although uncommon, Köhler's disease should be considered in the differential diagnosis of pediatric foot pain to avoid unnecessary treatments and to ensure optimal care for the patients.

A growing number of children and adolescents are being diagnosed as Chiari malformation type I (CM-I) for behavioral disorders, developmental delay, seizures, or abnormal orpharyngeal function. The aim of this study was to compare the clinical characteristics, imaging findings and surgical outcomes of CM-I in pediatric and adult patients. Between January 2014 and June 2017, 84 patients with CM-I underwent surgical treatment in our department. We divided the patients into two groups: pediatric group (n=11, age <18 years) and adult group (n=73, age ≥18 years). Data on clinical characteristics, imaging findings, surgical outcomes, and prognosis were retrospectively reviewed and compared between these two groups. For clinical presentation, scoliosis (36.4%) and developmental delay (36.4%) were more common in pediatric patients, whereas, sensory disturbance (58.9%) and motor weakness (41.1%) were more common in adult patients. Imaging findings showed that the incidence of hydrocephalus and craniovertebral junctional abnormalities was significantly higher in pediatric group than in adult group (P<0.05). Compared to adult group, pediatric group showed a better improvement or resolution of syrinx and tonsillar herniation after surgical treatments (P<0.05). The total Chicago Chiari Outcome Scale (CCOS) score in pediatric patients at the last followup was significantly higher than that in adult patients (P=0.002). In conclusion, the clinical characteristics and imaging findings appeared to be different in pediatric and adult patients with CM-I. The surgical outcomes of pediatric patients were shown to be significantly better than those of adult patients.