Extensive Bone Marrow Edema Research Articles

Case report: Tuberculosis as a cause unilateral of sacroiliitis in lupus patients

Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease, with variable manifestations, which is frequently exacerbated, requiring differential diagnosis with infectious conditions. In the case report, the patient satisfied the following criteria as per ACR/EULAR (2019): FAN 1:640 homogeneous nuclear, fever, alopecia, hypocomplementemia, antidsDNA 1:80 and lymphopenia. She was on: prednisone 20mg/day, hydroxychloroquine 400mg/day and calcium+vitamin D3. She was pale (3/4+), dehydrated and tachycardic. Osteoarticular examination: Patrick-Fabere positive for left sacroiliac; pain in external and internal rotation in left hip and painful palpation in the metacarpal, proximal interphalangeal, wrists, knees, ankles, hip and thigh joints, especially in the left and right. Radiography showed extensive sclerosis (grades 3 and 4) in left sacroiliac and rectified lumbar lordosis. Later, magnetic resonance imaging revealed extensive subcortical bone marrow edema at the left sacroiliac associated with capsulitis. In addition to positive BAAR TRM-TB, Lupus patients present a high incidence of TB, which is an important hypothesis in febrile cases with inflammatory lombalgy, since its osteoarticular form mainly affects the spine. Therefore, the importance of differential diagnosis for effective management is evident.

Clinical and magnetic resonance imaging feature differences between solitary and multiple type Langerhans cell histiocytosis involving the craniofacial bone

PurposeTo investigate the clinical and contrast-enhanced magnetic resonance imaging (MRI) features of craniofacial bone Langerhans cell histiocytosis (LCH) and discuss the differences between a solitary lesion group (SLG) and multiple lesions group (MLG). MethodThis study included 22 consecutive patients with pathologically proven LCH who underwent contrast-enhanced MRI. The clinical data and MRI features were retrospectively assessed. ResultsThe mean patient age was 5 years, and 15 patients were male. The frontal bone was the most frequently affected bone. Ten and 12 patients were classified into the SLG and the MLG, respectively. The following MRI features were observed in >50% cases: T1WI hyperintensity in 15 (68%) cases, T2WI hyperintensity in 16 (73%) cases, bulging sign in 18 (82%) cases, concentric or eccentric soft tissue mass formation in 13 (59%) cases, soft tissue edema in 16 (73%) cases, any grade of bone marrow edema in 16 (73%) cases, surrounding bone enhancement in 17 (77%) cases, and surrounding soft tissue enhancement in 16 (73%) cases. Patient age was significantly higher in the SLG than that in the MLG (P = 0.0014). Perilesional bone marrow edema and enhancement were significantly more prominent in the SLG than in the MLG (P = 0.032, P = 0.040). ConclusionsContrast-enhanced MRI showed additional significant findings of mainly the surrounding details. Older age, extensive bone marrow edema, and enhancement may indicate solitary-type LCH rather than multiple-type LCH. These differences may help distinguish between solitary- and multiple-type LCH, which have different treatment strategies.

Spinal osteoblastoma: a retrospective study of 35 patients\u2019 imaging findings with an emphasis on MRI

ObjectiveTo investigate the values of multimodal imaging approaches in the diagnosis of spinal osteoblastomas with an emphasis on MRI findings.Materials and methodsWe retrospectively evaluated the imaging findings of 35 patients with spinal osteoblastomas. The imaging methods included radiography, whole-body bone scintigraphy (WBBS), CT and MRI.ResultsRadiography detected 87.1% (27/31) of the lesions; WBBS demonstrated increased radionuclide activity in all the lesions. CT could precisely show and localize all niduses, and calcification was always detected. MRI usually could adequately delineate the niduses of osteoblastomas, especially on T2WI (88.2%; 30/34). 71.9% (23/32) of osteoblastomas were surrounded with moderate or extensive bone marrow edema (BME) with soft tissue edema (STE). STE always extended along the muscle bundle adjacent to the lesion; there was no subcutaneous fat involvement. BME was eccentrically distributed in the vertebral body and spread inward from the sides of the nidus. The extent of BME in the vertebral body tended to be inversely proportional to the distance from the nidus. In addition, rare magnifications of osteoblastoma including multifocal diseases (n = 2), vertebra plana (n = 1) or with aneurysmal bone cysts (n = 6) were also observed in our study.ConclusionsIn patients showing moderate or extensive BME together with STE on MRI, both CT and MRI should be used to confirm nidus presence. The above-mentioned characteristics of edema on MRI of patients with spinal osteoblastoma are helpful in not only localizing the nidus, but also enhancing the diagnostic confidence.

Predicting Bone Marrow Edema and Fracture Age in Vertebral Fragility Fractures Using MDCT.

OBJECTIVE. The purpose of this study was to evaluate whether CT features can predict bone marrow edema (BME) on MRI and fracture age in vertebral fragility fractures. MATERIALS AND METHODS. A total of 189 thoracolumbar compression fractures in 103 patients (14 men, 89 women; mean age, 76 years) imaged with both spine CT and MRI were retrospectively included. The presence and extent of BME were assessed on MRI to divide fractures into those with and without BME. The group with BME was then classified for subgroup analysis into fractures with extensive BME (comprising 50% or more of the vertebral body) and those with BME comprising less than 50% of the vertebral body. On CT, five features (presence of cortical or endplate fracture line, presence of trabecular fracture line, presence of condensation band, change in trabecular attenuation, and width of paravertebral soft-tissue change) were analyzed. RESULTS. All five CT findings were predominantly seen in fractures with BME (p < 0.001). Elevated trabecular attenuation, presence of a cortical or endplate fracture line, and paravertebral soft-tissue width showed excellent diagnostic indication for fractures with BME (ROC AUCs: 0.990, 0.976, and 0.950, respectively). In the subgroup with extensive BME, paravertebral soft-tissue width was significantly higher, whereas the change in trabecular attenuation was lower compared with those with BME comprising less than 50% of the vertebral body (p < 0.001). When BME was present, fracture age was not significantly different between the two subgroups, and only greater trabecular attenuation elevation was predictive of older fracture age on linear mixed model analyses (p < 0.001). Interobserver agreement was good for the trabecular fracture line factor and excellent for all other factors. CONCLUSION. CT features accurately correlate with the presence and extent of BME in vertebral fragility fractures. Elevation of trabecular attenuation was the only significant image predictor of fracture age.

Intra-articular osteoid osteoma accompanied by extensive bone marrow edema. A clinical and micro-morphological analysis

Osteoid osteoma (OO) is a benign bone tumor producing non-mineralized bone matrix (i.e., osteoid). While peritumoral edema is commonly found in OO, extensive bone marrow edema has been reported less frequently. Furthermore, the micro-morphological characteristics of the nidus and its central calcification remain unclear. In this study, a consecutive series of four patients suffering from extensive bone marrow edema triggered by intra-articular osteoid osteoma underwent clinical examination, magnetic resonance imaging (MRI) and computed tomography (CT) as well as dual-energy X-ray absorptiometry (DXA) and laboratory bone turnover analyses. The obtained resection specimens were processed by undecalcified histology and were subsequently analyzed by light microscopy and quantitative backscattered electron imaging (qBEI). We report an entity of intra-articular osteoid osteoma in the knee and foot, in which an extensive and persistent bone marrow edema syndrome masked the correct diagnosis. While metabolic bone diseases were excluded in all cases, the reassessment of the patients’ clinical history including pain characteristics (nocturnal, aspirin sensitivity) led us to perform additional CT, where the tumor was diagnosed. The micro-morphological analysis of the OO biopsies revealed that the nidus was surrounded by hyperosteoidosis, while central mineralization was detected in all cases. This mineralized area showed a significantly higher mineralization heterogeneity than the surrounding trabecular bone and more disorganized collagen fibers detected by qBEI and polarized light microscopy, respectively. Taken together, our results indicate that osteoid osteoma should be considered when persistent and extensive, peri-articular bone marrow edema is diagnosed. The central calcification that is found inside the nidus in conventional imaging was mirrored by bone matrix with a heterogeneous mineralization pattern.

Osteomyelitis After Deadlifting Injury- A Rare Case Of A Burst Abscess

HISTORY: 68-yr old male weightlifter presented with 1 mo. L buttock pain, acute onset of popping mid-lift during a deadlift, with radiating vague pain in L buttock. He continued to exercise through pain and 1 wk later pain progressed to severe deep buttock pain and difficulty ambulating. Denied low back pain, radiating thigh/leg symptoms, numbness/tingling, weakness, or bowel/bladder changes. Past hx positive for melanoma (treated in remote past), social hx negative for smoking, drug/alcohol abuse. He initially went to outside facility (only lumbar x-rays taken) without improvement, came in for another opinion with progressive symptoms. PHYSICAL EXAMINATION: Skin normal without warmth, erythema. Vague tenderness in region of L buttock and SI joint. Full lumbar spine and hip ROM. Negative SLR. Mild nonspecific back discomfort with FABER. Normal lower limb neurovascular exam. DIFFERENTIAL DIAGNOSIS: 1. SI Joint Dysfunction 2. Lumbar Radiculopathy 3. Piriformis Syndrome 4. Lumbar or Sacral Compression Fracture 5. Metastatic Cancer 6. Sacroiliitis TEST AND RESULTS: Outside lumbar x-rays negative for fracture, showed minimal degenerative disc changes. We obtained hip/pelvis radiographs showing significant erosions and destructive changes of L SI joint. An urgent MRI showed fluid-filled and widened SI joint, severe inflammatory sacroiliitis with extensive erosions and bone marrow edema, widespread reactive muscle edema (iliacus showing fluid collection/early abscess at SI joint); SI joint aspirate was obtained. FINAL WORKING DIAGNOSIS: septic sacroiliac arthritis with iliacus abscess and secondary osteomyelitis; aspirate grew staphylococcus aureus (MSSA). TREATMENT AND OUTCOMES: The patient had a unique etiology of osteomyelitis not commonly reported. Orthopedics and ID determined he had pre-existing asymptomatic abscess that ruptured. Under the extreme abdominal pressures of deadlifting, they felt abscess burst leading to local spread and secondary osteomyelitis. This case highlights the rapidity and widespread destruction of infectious arthritis and need for awareness and prompt workup. Patient was treated with 6 wks of oxacillin and responded well. He returned to baseline physical activity at follow up; repeat x-rays showed SI joint sclerosis and patient was counseled on SI joint arthritis.

A bizarre parosteal osteochondromatous proliferation (Nora's lesion) of metatarsus, a histopathological and etiological puzzlement

Nora's lesion (bizarre parosteal osteochondromatous proliferation) is a rare, benign lesion that is composed of differing amounts of cartilage, bone, and spindle cells and an unusual form of calcified cartilage so-called “blue bone”. Whether it represents a reactive proliferation or a neoplastic lesion still remains controversial. We present a 24-year-old woman having a 4.5cm two lobulated mass attached to second metatarsus of her left foot. The lesion was hyperintense on magnetic resonance imaging and accompanied by an extensive soft tissue and bone marrow edema. In resection specimen, smaller lobule appeared stuck-on the cortex while the larger one had a broader base and a 0.4cm cartilaginous cap-like formation. The histological picture was best fit to Nora's lesion however showed less fibroblastic tissue and cartilaginous pleomorphism. The lesion also showed areas with cortical invasion and a small focus of fracture callus accompanied by adjacent medullary edema and fat necrosis. The case is presented with the comparative radiologic, macroscopic and microscopic findings for its diagnostic difficulties and etiopathogenetic considerations in favour of a maturation phenomenon in parosteal ostecartilaginous lesions irrespective of the cause.

Relevance of the gut/joint axis for the management of spondyloarthritis in daily clinical practice.

Thirty years ago, the concept of microscopic gut inflammation in spondyloarthritis (SpA) was established. Over the past decade, there has been tremendous progress in the earlier diagnosis of SpA. In addition, it has been suggested that, because of improved hygiene over the past years, exposure to microorganisms has changed, leading to a shift in diseases, for example, a decreased incidence of reactive arthritis. It is therefore necessary to re-establish the role of gut inflammation in SpA. The prevalence of microscopic gut inflammation could be confirmed in c. 50% of patients with early axial and/or peripheral SpA. More importantly, a predictive model could be developed linking gut inflammation with clinical factors, that is, higher disease activity, extensive sacroiliac bone marrow edema, and progressive disease. In addition, there is increasing evidence indicating that the presence or absence of gut inflammation in SpA may influence therapeutic decision-making in the future. A clear demonstration of this is the different efficacy of IL-17 blockade in Crohn's disease versus SpA. Microscopic gut inflammation is present in almost 50% of SpA patients and appears relevant for prognosis and therapeutic decision-making. SpA patients with the chronic type of gut inflammation seem to have a less favorable disease course. It is therefore conceivable that assessment of gut inflammation should be included in future models for risk stratification of SpA.

A104: Aggressive Erosive Synovitis in Juvenile Idiopathic Arthritis

Background/Purpose:Plain radiographs (x‐rays) are useful in the evaluation of children with JIA. Bone erosions are one of the finding that can be seen on x‐rays. However, they are most often reported in the polyarticular RF+ subtype of JIA and are rare in most other subtypes.Methods:Herein 3 patients with JIA are presented whose diagnoses were questioned after plain x‐rays were obtained. MRI later revealed significant erosive disease in these patients.Results:Case 1: A 14 yo male presented with a monoarthritis of the left wrist. Initial x‐rays were normal. His work‐up was unremarkable. His inflammatory markers were normal. He was thus diagnosed with JIA–oligoarthritis. After 6 months in remission, after the use of an NSAID, he flared in the same joint. Repeat x‐rays showed a radiolucent area with associated sclerosis in the scaphoid of unclear etiology. An MRI was thus requested. It revealed synovitis associated with erosive disease. Post gadolinium injection, a geode in the scaphoid bone with marked synovial enhancement visible within this erosion was detected. He underwent a joint injection which put him into remission. Repeat x‐rays one year later, revealed unchanged findings likely corresponding to the non‐healed erosion.Case 2: An 11 yo HLA B27 + male diagnosed with ERA with polyarthritis of the lower limbs and sacroiliac joints was treated with methotrexate and an NSAID. Investigations ruled out IBD and the arthritis was felt to be well controlled despite persistently elevated inflammatory markers of unclear etiology. He presented with a severe flare in his knees and ankles. X‐rays revealed well‐defined lytic lesions in the anterior aspect of the proximal tibial metaphysis just below the growth plate bilaterally. Given the concern of an infiltrative process, an MRI was obtained. Post gadolinium injection, a large erosion of the tibial plateau with marked synovial enhancement within this erosion was seen, as well as a knee synovitis. Etanercept was started.Case 3: An 8 yo male presented with a monoarthritis of the right wrist evolving for five months after an initial minor trauma. X‐rays revealed advanced bone maturation of the right wrist as well as a sclerotic lesion of the hamate. Given the initial trauma, an MRI was obtained which demonstrated very extensive bone marrow edema, synovitis, tenosynovitis and a large erosion within the hamate. A diagnosis of JIA–oligoarthritis was made. He underwent a joint injection with good disease control.Conclusion:Large erosions are not typical for some JIA subtypes such as oligoarthritis and ERA. Findings on x‐rays led the treating physicians to question the underlying diagnosis however, MRI revealed very aggressive synovitis of the wrist and knee in these patients. MRI was useful to demonstrate the presence of synovial enhancement within the eroded bone and helped rule out another diagnosis. Awareness of this type of aggressive arthritis is needed so that patients are not over‐investigated and prompt treatment can be offered.

The pathogenesis of rheumatoid arthritis in radiological studies. Part I: Formation of inflammatory infiltrates within the synovial membrane and I. Sudoł-Szopińska, K. Zaniewicz-Kaniewska, A. Warczyńska, G. Matuszewska, F. Saied, W. Kunisz The pathogenesis of rheumatoid arthritis in radiological studies. Part II: Imaging studies in rheumatoid arthritis.

In the recent years, musculoskeletal ultrasound (US) has been developing rapidly as a method evaluating the intensity of the inflammatory process in inflammatory joint diseases including rheumatoid arthritis (RA). The series of articles entitled: The pathogenesis of rheumatoid arthritis in radiological studies (parts 1 and 2)(1, 2) enable a deeper insight into the relation between the disease progression and changes visible on imaging such as US and magnetic resonance imaging (MRI). As the authors of the articles emphasize, these methods are important for the determination of the exact natural course of the disease, diagnostic differentiation of RA as well as monitoring its activity. The changes which could suggest RA in US exams are pathologies of the synovial membrane of the joints and tendon sheaths, joints and tendon sheaths effusion as well as erosions. On the other hand, the presence of enthesitis suggests the inflammation of the peripheral joints in the course of spondyloarthropathy such as psoriatic arthritis or ankylosing spondylitis. In the study of Narvaez et al., enthesitis, extensive bone marrow edema of the hand and wrist bones, diffuse soft tissue swelling of the hand and wrist and, to a certain extent, the involvement of the flexor tendons in MRI distinguished psoriatic arthritis from RA(3). In the US examination, at the early stage of arthritis, it is essential to check some joints for the presence of lesions which typically indicate that RA may develop in the later course of the disease. The research of Filer et al. shows that during the first US exam of the patients who developed RA, the following were diagnosed: subclinical synovitis of wrists, elbows, knees, ankle joints, metatarsophalangeal joints (MTP) and metacarpophalangeal joints (MCP)(4). The inflammation of large joints as well as proximal interphalangeal joints visualized during the US examination were of low prognostic value. The most important prognostic factor in RA development was the diagnosis of synovitis in the grey-scale US examination of the wrists and MCP joints as well as MTP joints synovitis in the power Doppler US. Therefore, US examinations of the wrists, MCP and MTP joints should always be performed in patients suffering from early arthritis with high-risk of RA development. In addition, it needs to be mentioned that joints ultrasound in patients receiving pharmacological treatment for early RA, facilitates the detection of minimum inflammatory activity with greater sensitivity than physical examination. Synovial hypertrophy with hypervascularization in power Doppler US enables the recognition of active inflammation in patients in a stage of clinical remission. In a study based on 48 patients with early RA, the US examination confirmed the clinical remission in 67% of the subjects(5). Simultaneously, the exacerbation of the disease occurred in 47% of the patients in remission of early arthritis in whom the power Doppler signal was present. Out of the patients in whom there was no power Doppler signal in the synovial membrane, the disease exacerbation occurred in merely 20% of cases.

Onycho-Pachydermatit with extensive bone marrow edema predominant in the metacarpals: a “forme fruste” of POPP?

Psoriatic onycho-pachydermo-osteo/periostitis (POPP) syndrome is a rare form of psoriatic arthritis with a combination of (i) psoriatic onychodystrophy, (ii) connective tissue thickening, and (iii) periostitis of the distal phalanges. The treatment of the condition has generally been reported to be unsatisfactory with the traditional regimes. Here, we describe a case whom we believe is one presentation of POPP with extensive bone marrow edema of metacarpal bones without distinctive periostitis.

Focal Articular Cartilage Defect Treated by Percutaneous Radiofrequency Ablation

A 30-year-old man presented with a painful intraarticular lesion in the knee, clinically simulating osteoid osteoma. Pretherapeutic imaging disclosed a focal articular cartilage defect located in the medial femoral condyle and surrounded by extensive bone marrow edema. The defect was inaccessible for arthroscopic treatment because of its unusual posterosuperior location. Percutaneous radiofrequency ablation was then performed under computed tomography guidance, resulting in complete resolution of symptoms. Magnetic resonance imaging follow-up found resolution of the bone marrow edema pattern around the lesion and growth of fat in the site of the previous lesion.

Transient osteoporosis of the hip and spontaneous osteonecrosis of the knee: a common aetiology?

The aetiologies of transient osteoporosis of the hip (TOH) and spontaneous osteonecrosis of the knee (SONK) are still unknown. Both entities present with pain and extensive bone marrow oedema is seen on magnetic resonance imaging. We describe a patient who presented with TOH and later also developed SONK. Initial magnetic resonance imaging findings of both the hip and the knee showed extensive bone marrow oedema and a subchondral fracture line suggesting that subchondral fractures might be of importance to the aetiology of both conditions. To our knowledge, this is the first case report that describes the occurrence of TOH and SONK in the same patient and introduces the possibility of a common aetiology.

Imaging features of foot osteoid osteoma

We performed a retrospective review of the imaging of nine patients with a diagnosis of foot osteoid osteoma (OO). Radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) had been performed in all patients. Radiographic features evaluated were the identification of a nidus and cortical thickening. CT features noted were nidus location (affected bone-intramedullary, intracortical, subarticular) and nidus calcification. MRI features noted were the presence of an identifiable nidus, presence and grade of bone oedema and whether a joint effusion was identified. Of the nine patients, three were female and six male, with a mean age of 21 years (range 11-39 years). Classical symptoms of OO (night pain, relief with aspirin) were identified in five of eight (62.5%) cases (in one case, the medical records could not be retrieved). In five patients the lesion was located in the hindfoot (four calcaneus, one talus), while four were in the mid- or forefoot (two metatarsal and two phalangeal). Radiographs were normal in all patients with hindfoot OO. CT identified the nidus in all cases (89%) except one terminal phalanx lesion, while MRI demonstrated a nidus in six of nine cases (67%). The nidus was of predominantly intermediate signal intensity on T1-weighted (T1W) sequences, with intermediate to high signal intensity on T2-weighted (T2W) sequences. High-grade bone marrow oedema, limited to the affected bone and adjacent soft tissue oedema was identified in all cases. In a young patient with chronic hindfoot pain and a normal radiograph, MRI features suggestive of possible OO include extensive bone marrow oedema limited to one bone, with a possible nidus demonstrated in two-thirds of cases. The presence or absence of a nidus should be confirmed with high-resolution CT.

Pubic Magnetic Resonance Imaging Findings in Surgically and Conservatively Treated Athletes with Osteitis Pubis Compared to Asymptomatic Athletes during Heavy Training

Background Osteitis pubis is characterized by diffuse pain, inflammation, and bony changes in the pubic symphysis. Bone marrow edema in magnetic resonance imaging is associated with stress injury and osteitis of the pubic bone. Hypothesis Laparoscopic mesh repair decreases inflammation and pain in the pubic periosteum. The presence of extensive bone marrow edema may correlate with the severity of symptoms and may guide the surgical treatment of osteitis pubis. Study Design Case control study; Level of evidence, 4. Methods Surgery (n = 8) was performed by placement of totally extraperitoneal endoscopic mesh behind the symphysis. Nonoperative treatment (n = 8) included physical therapy and corticosteroids. Preoperative and postoperative pain was measured by the visual analog scale. Athletes were followed up from 1 to 6 years (mean, 2.7 years). All magnetic resonance imaging scans were analyzed blindly by 2 radiologists. Twenty asymptomatic ice hockey or soccer players served as controls in magnetic resonance imaging. Results The patients treated surgically had higher preoperative pain scores than did the patients treated conservatively. Seven of 8 athletes (88%) treated surgically returned to sport activities after 2 months of convalescence. No complications were associated with surgery. In the nonoperative group, 4 patients (50%) still had disabling symptoms after 1 year of follow-up, and they stopped their elite sports during 3 years of follow-up. The presence of bone marrow edema was distributed in the surgical (100%), nonoperative (88%), and asymptomatic athletes (65%) with no statistical difference between the groups. Conclusion This study indicated that the placement of retropubic mesh was an efficient method for the treatment of severe pubic enthesopathy in athletes. Abnormal magnetic resonance imaging findings were also common in asymptomatic athletes, which decreases the value of magnetic resonance imaging in surgical decision-making.

The skiers knee without swelling or instability, a difficult diagnosis: a case report

Skiing as a recreational activity has increased exponentially in the last twenty-years. Similar to any sporting activity, participants can sustain various types of injury, which provides the emergency departments with a continuous supply of patients. The injury pattern from the slopes has also changed over this time period, due to alterations and improvements in ski equipment. An increased diversity in alpine skiing techniques, as well as snowboarding and cross-terrain disciplines has also influenced this change.We present a multi-media experience of a high-speed ski fall that caused a valgus-external rotation injury to the right knee that precluded the patient from further ski activity. There was no bruising, swelling or instability demonstrated and the patient returned to ski activities 24-hours post-injury. Although this injury appeared clinically benign initially, the patient complained of persistent pain around the right knee which was causing occupational difficulties. Following normal clinical assessment, the patient returned to work but continued to complain of persistent pain at the lateral aspect of the right knee. Magnetic Resonance Imaging (MRI) demonstrated extensive bone marrow oedema (BMO), a mild depression of the articular cortex compression with a small focus of articular cartilage disruption and microfractures of the lateral tibial plateau. The patient was treated conservatively and remains well with avoidance of impact exercises 14-months post-injury.In the presence of any high speed injury, we would stress that regardless of initial normal investigations, clinical suspicion should remain paramount and not deter the physician from further investigation in the presence of continuing symptomatology.

A Chondroblastoma Versus a Giant Cell Tumor: Emphasis on the MR Imaging Features

Purpose: To assess the MR imaging features in differentiating a chondroblastoma (CB) from a giant cell tumor (GCT), with an emphasis on the accompanying peritumoral bone marrow edema. Materials and Methods: MR imaging findings in 20 patients with CB were compared with the imaging features of 22 patients with GCT. The location of the lesion, signal intensity, adjacent cortical change, degree of accompanying bone marrow edema, synovitis in the adjacent joint and cystic change were analyzed. The findings of CB and GCT were examined statistically with use of Fisher's exact test. Results: The incidence ratios of MR imaging findings were as follows (CB:GCT). Metaphyseal dominant involvement (2:21), partial cortical disruption (2:14), extensive bone marrow edema surrounding the tumor (14:0) and synovitis in the adjacent joint (11:2) were statistically different in incidence between CB and GCT (p

Percutaneous Vertebroplasty: Relationship between Vertebral Body Bone Marrow Edema Pattern on MR Images and Initial Clinical Response

To prospectively investigate the relationship between initial clinical response and bone marrow edema pattern on preprocedural magnetic resonance (MR) images in vertebral bodies selected for percutaneous vertebroplasty (PVP). Institutional review board approval and written informed consent were obtained. PVP was performed for osteoporotic compression fractures in 80 consecutive patients (mean age, 72.4 years; range, 44-85 years; 67 women and 14 men; 157 vertebrae). Patients were divided into three groups according to the proportion of the vertebra in which the bone marrow edema pattern was observed on sagittal MR images: group 1, 50% or more of the vertebra; group 2, less than 50%; group 3, no edema pattern observed. By using Wilcoxon rank sum test, Fisher exact test, and Wilcoxon signed rank test, groups were examined for differences in treatment efficacy, which was defined as the difference between preprocedural and postprocedural pain as assessed by means of visual analog scale (VAS) score at 1-3 days after PVP. Forty-four patients were assigned to group 1, 14 to group 2, and 22 to group 3. No significant difference was seen between the groups with respect to age, sex, number of treated vertebrae, or preprocedural VAS score. In group 1, VAS score decreased from 7.5 before the procedure to 2.9 after (improvement of 4.6). In group 2, the score decreased from 6.8 to 3.1 (improvement of 3.7). In group 3, the score decreased from 7.0 to 4.3 (improvement of 2.7). Improvement was significantly greater in group 1 than in group 3 (P < .005). PVP resulted in significantly greater clinical improvement in patients with an extensive bone marrow edema pattern than in those without this pattern. (c) RSNA, 2006.

Lesion of the Right Proximal Tibia in a 12-Year-Old Boy

Lesion of the Right Proximal Tibia in a 12-Year-Old Boy

BILATERAL HEEL PAIN IN AN ADOLESCENT RUNNER

HISTORY 15 year old cross country runner complaining of bilateral heel pain, right greater than left, for three weeks shortly after the onset of the season. He denies any trauma or specific injury. He denies any night pain or paresthesias. He reports the pain primarily on the medial and lateral sides of the heel bilaterally. He does report some morning stiffness and increased heel pain going down stairs. PHYSICAL EXAMINATION His gait is normal. There is pes planus bilaterally. There are no skin changes. There is some retrocalcaneal area tenderness bilaterally. There is no heel cord tenderness although there is mild associated tightness of the Achilles tendon bilaterally. There is pain with side to side calcaneal compression in both extremities. The origin of the plantar fascia is nontender and there is no plantar surface tenderness. There is no ankle instability and manual muscle testing is slightly diminished throughout. There is no neurovascular deficiency. DIFFERENTIAL DIAGNOSIS Calcaneal apophysitis. Calcaneal stress fracture. Retrocalcaneal bursitis. Tarsal tunnel syndrome. Pathologic fracture through a bone cyst. Plantar Fasciitis. Heel pad syndrome. TEST RESULTS Bilateral foot and ankle radiographs:–A/P, lateral and axial views without obvious osseous abnormality and essentially closed physes. Bilateral foot and ankle MRI:– There is a calcaneonavicular coalition in both feet. In addition, there is extensive bone marrow edema within each calcaneus and osseous changes consistent with stress fracture. There is also abnormal thickening of the ATF and CF ligaments and intermediate signal within the flexor hallucis longus tendon suggestive of chronic injury. FINAL/WORKING DIAGNOSIS Bilateral calcaneal stress fractures with underlying tarsal coalition and chronic tendonopathy. TREATMENT AND OUTCOMES Nonweightbearing with crutches and immobilization in a low tide walker boot for the right (more symptomatic) side for 4 weeks. Subsequent ankle rehabilitation. Return to sport when there is normal strength, ROM and resolution of pain with strenuous activity. If symptoms persist beyond this time or recur, consideration will be given to surgical correction of the underlying tarsal coalitions.