Intra-articular Loose Bodies Research Articles

Imaging of Hip and Groin Athletic Injuries

SummaryHip and groin injuries are usually seen with kicking, running and jumping athletic activities. Both recreational and elite athletes can be involved with hip and groin injuries. Although not very common, sports‐related injuries of the hip and groin may impose a significant diagnostic dilemma for both the clinicians and the radiologists. Delayed diagnosis and treatment may result in complications, such as permanent disability or premature degenerative joint disease. Plain X‐rays are the initial examination although usually unremarkable. Computed tomography can be helpful in certain cases such as tiny avulsion injuries, intraarticular loose bodies and myositis ossificans. Magnetic resonance (MR) imaging of the hip and groin area has proven to be extremely valuable in the diagnosis of radiographically occult osseous abnormalities as well as musculotendinous injuries. MR imaging is helpful in clinically confusing disorders such as stress bone marrow reactions and bursitis. MR imaging following the intraarticular administration of gadolinium is valuable for evaluating the cartilaginous, osteochondral and acetabular labral injuries. The osseous and soft tissue conditions summarized in this article represent those most commonly considered in the differential diagnosis of hip and groin injuries in athletes.

Arthroscopic Surgery to Treat Intra-articular Type Snapping Hip

To reveal the causes of the intra-articular type snapping hip and their frequency. Case series. We studied 2 hip joints of 2 male patients and 30 hip joints of 28 female patients with snapping hip syndrome, in which the accompanying pain was transiently relieved by intra-articular injection of local anesthetic. The mean age at diagnosis was 26 years. Plain radiography, hip arthrography, magnetic resonance imaging (MRI), and arthroscopy were performed in these patients and the findings were compared. Plain radiography findings showed no abnormality in 11 joints, hip osteoarthritis in 19 joints, and femoral head deformation caused by Perthes disease and synovial osteochondromatosis in 1 joint each. Excluding the case of synovial osteochondromatosis, 31 joints were examined by MRI, which failed to identify the cause of snapping hip in all cases. Hip arthrography revealed an intra-articular loose body in 2 joints with osteoarthritis. Arthroscopy revealed acetabular labral tears in all 11 joints with no abnormalities and 15 of 19 joints with osteoarthritis on plain radiography films, and incompatibility between acetabular labrum and deformed femoral head in 2 joints with osteoarthritis. In the case of femoral head deformation after Perthes disease, arthroscopy revealed detachment of the femoral head cartilage as a result of impingement of the acetabulum on the femoral head. Arthroscopic surgeries were conducted: partial limbectomy for acetabular labral tears, surgical removal of loose bodies, partial femoral head excision for incompatibility between acetabular labrum and deformed femoral head, and shaving or articular cartilage detachment. The surgeries resolved the snapping in all cases. Acetabular labral tear was the cause of 80% of cases of intra-articular type snapping hip. Incompatibility between the acetabular labrum and a deformed femoral head was found to be a cause of intra-articular type snapping hip. Level IV, case series.

Arthroscopic Management of Intra-articular Hip Disorders in Active-Duty Military Patients

Hip arthroscopy has become an invaluable tool for addressing intra-articular hip pathology in the active-duty soldier. The surgical indications for hip arthroscopy are evolving, but our primary indications have been for hip labral tears, snapping psoas tendons, and intra-articular loose bodies. As in elite athletes, the demands placed on the hip joint by active-duty soldiers, especially in combat, are tremendous. The differential for hip pain in this population is long and broad. The most common intra-articular injury seen in this population is an acute acetabular labral tear. Clinical examination and imaging studies can often times be inconclusive in the workup of patients with labral tears. Definitive diagnosis and treatment can be obtained through hip arthroscopy. Traditionally, the treatment for hip labral tears has been debridement, but, recently, we have transitioned to repairing peripheral longitudinal tears, similar to those seen in the knee meniscus. Although long-term results are not yet known, short-term follow-up shows good to excellent results with arthroscopic acetabular labral repair. This article describes indications and surgical technique for hip arthroscopy in young active-duty soldiers.

Radiography of the elbow for evaluation of patients with osteochondritis dissecans of the capitellum

This study was performed to determine the ability of a routine radiographic examination of the elbow to detect osteochondritis dissecans of the capitellum and associated intra-articular loose bodies. The study group consisted of 15 patients with osteochondritis dissecans of the capitellum confirmed by surgery or magnetic resonance imaging. Seven of the 15 patients had associated intra-articular loose bodies confirmed by surgery. All 15 patients had anteroposterior and lateral radiographs and magnetic resonance imaging of their symptomatic elbow. Nine of the 15 patients had subsequent elbow surgery. We reviewed the original interpretations of the radiographic examinations of the elbow of all 15 patients to determine whether osteochondritis dissecans of the capitellum and associated intra-articular loose bodies had been identified prospectively. We also reviewed the elbow radiographs of all 15 patients to determine whether osteochondritis dissecans of the capitellum and associated intra-articular loose bodies could be identified retrospectively. Osteochondritis dissecans of the capitellum was detected during the initial interpretations of the radiographic examinations of the elbow in seven of 15 patients. Osteochondritis dissecans of the capitellum was detected during retrospective review of the elbow radiographs in 10 of 15 patients. Intra-articular loose bodies were detected during the initial interpretations of the radiographic examinations of the elbow in three of seven patients. Intra-articular loose bodies were detected during retrospective review of the elbow radiographs in four of seven patients. A routine radiographic examination of the elbow has limited sensitivity for detecting osteochondritis dissecans of the capitellum and associated intra-articular loose bodies.

MRI abnormalities of the external rotator muscles of the hip

Unilateral hip pain is a common condition with many causes. It is well described after traumatic hip dislocation. MRI changes after traumatic hip dislocation have also been well documented and include soft tissue, bone, cartilaginous and muscle injury. Posterior dislocation is the most common type of hip dislocation, and patients may develop a pattern of muscle injury specific to this type of injury. Laorr et al. reported injury to the piriformis, quadratus femoris, superior and inferior gemelli (gluteal region), pectineus (anterior compartment), and the adductor brevis and obturator externus (medial compartment) in all patients sustaining traumatic hip disclocation. In comparison with anterior dislocations, posterior dislocations demonstrated more severe muscle trauma and in 50% there was abnormality in the posterior fascial compartment. No abnormality was seen in this compartment in anterior dislocations. Other features of hip dislocation include fractures (more common with posterior dislocations), disruption of the iliofemoral ligament, intra-articular loose bodies and soft tissue injury. However, to date there has been little in the literature regarding any association of hip pain with abnormality in these muscles. The gemelli, quadratus femoris, obturator externus and piriformis principally act as external hip rotators. With the exception of obturator externus they also act as abductors (most strongly with the hip flexed) and adductors.

Osteochondromas of the Talus Presenting as Intraarticular Loose Bodies: Report of Two Cases

Osteochondromas of the Talus Presenting as Intraarticular Loose Bodies: Report of Two Cases

Whole-Organ Magnetic Resonance Imaging Score (WORMS) of the knee in osteoarthritis

Objectives: To describe a semi-quantitative scoring method for multi-feature, whole-organ evaluation of the knee in osteoarthritis (OA) based on magnetic resonance imaging (MRI) findings. To determine the inter-observer agreement of this scoring method. To examine associations among the features included in the scoring method. Methods: Nineteen knees of 19 patients with knee OA were imaged with MRI using conventional pulse sequences and a clinical 1.5 T MRI system. Images were independently analyzed by two musculoskeletal radiologists using a whole-organ MRI scoring method (WORMS) that incorporated 14 features: articular cartilage integrity, subarticular bone marrow abnormality, subarticular cysts, subarticular bone attrition, marginal osteophytes, medial and lateral meniscal integrity, anterior and posterior cruciate ligament integrity, medial and lateral collateral ligament integrity, synovitis/effusion, intraarticular loose bodies, and periarticular cysts/bursitis. Intraclass correlation coefficients (ICC) were determined for each feature as a measure of inter-observer agreement. Associations among the scores for different features were expressed as Spearman Rho. Results: All knees showed structural abnormalities with MRI. Cartilage loss and osteophytes were the most prevalent features (98% and 92%, respectively). One of the least common features was ligament abnormality (8%). Inter-observer agreement for WORMS scores was high (most ICC values were >0.80). The individual features showed strong inter-associations. Conclusion: The WORMS method described in this report provides multi-feature, whole-organ assessment of the knee in OA using conventional MR images, and shows high inter-observer agreement among trained readers. This method may be useful in epidemiological studies and clinical trials of OA.

ELBOW PAIN???15 YEAR OLD BASEBALL PITCHER.

HISTORY A.15 year old high school baseball pitcher, who writes with his left hand and pitches with his right hand, presents with a one-year history of right elbow pain and stiffness. The onset of his symptoms was gradual. His pain is localized to the posteromedial and posterolateral aspects of his elbow. The symptoms are worsened after physical activities, especially after pitching. He has occasional episodes of clicking with the sensation of a loose object in his elbow in addition to episodic swelling and stiffness. His prior treatment had consisted of diminished pitch counts, physical therapy and ibuprofen without significant relief. PHYSICAL EXAMINATION Examination reveals no focal tenderness to palpation. A moderate joint effusion is appreciable. Range of motion testing reveals 15° lack of extension with 140° of flexion. The contralateral elbow has an arc of motion from 0° to 155°. He has full and painless forearm pronation and supination. Valgus stress testing is negative bilaterally. The rest of his upper extremity and neurologic testing was normal and symmetric. DIFFERENTIAL DIAGNOSIS Capitellar osteochontitis dessicans/Panner's disease. Synovial chondromatosis. Olecrenon stress fracture. Medial epicondyle physeal injury/flexor-pronator strain. Multiple epiphyseal dysplasia. Olecrenon apophysitis. Intraarticular loose body. Plica. Medial epicondylitis. TEST AND RESULTS Anteroposterior, Lateral and Oblique elbow radiographs:–officially read as no evidence of fracture, no significant joint effusion, normal appearing articular surfaces Elbow magnetic resonance imaging: –osteochondritis dessicans of the distal humeral trochlea with an intraarticular loose body FINAL/WORKING DIAGNOSIS Osteochondritis dessicans of the right elbow trochlea with an intraarticular loose body. TREATMENT AND OUTCOMES Arthroscopic loose body removal and synovectomy. Physical therapy for active and active assist elbow range of motion exercises. Restricted throwing. At three months postoperatively, he had an active range of motion of 10° to 145° and he was progressed to light overhead throwing. At 9 months followup he had a range of motion of 5° to 150° degrees and was asymptomatic with overhead throwing.

ELBOW INJURY-FOOTBALL

HISTORY A 15 year old freshman high school football player presented within 24 hours of injuring his right arm in a football game. While playing as a nose tackle, he was chop blocked. He fell and supported his body with his right arm with the elbow in extension. Immediately after the injury, he experienced numbness of the fourth and fifth digits of the right hand, which resolved in a few seconds. He did not experience any popping or buckling sensation during the injury. No manipulation or reduction of the elbow was attempted prior to the office visit. No previous elbow injuries. He is right hand dominant. PHYSICAL EXAMINATION Examination revealed a moderate right elbow effusion. No ecchymosis. The medial epicondyle and origin of the flexor pronator mass were tender to palpation. There is restricted flexion and extension (30–100 degrees) secondary to pain. Pronation and supination were painful. Valgus and varus stress at 0 and 30 degrees of elbow flexion without instability. No wrist or shoulder pain with passive or active range of motion. Right upper extremity was neurovascularly intact. DIFFERENTIAL DIAGNOSIS supracondylar fracture. elbow dislocation. radial head fracture. capitellum fracture. coronoid process fracture. medial epicondyle fracture. TESTS AND RESULTS AP/lateral/capitellum x-rays: Angulated radial head fracture. Approximately 30 degrees of apex ulnar angulation. Radial capitellar joint space widened almost 1 cm on lateral side. Avulsion fracture of medial epicondyle. FINAL/WORKING DIAGNOSIS Right elbow dislocation equivalent with radial head fracture. TREATMENT AND OUTCOME Open reduction and internal fixation of radial head fracture. Physical therapy – active and active-assisted ROM right elbow and forearm. Unlocked brace. Patient initially improved without problems. Then, 4 weeks post surgery developed decreased elbow flexion/extension as well as pronation/supination range of motion. Possible intra-articular loose body. Continue physical therapy. Follow-up in two weeks. Arthroscopy if no improvement in two weeks.

Magnetic resonance imaging of the hip: sports-related injuries.

Normal hip disorders do not account for a large proportion of exercise-related injuries, but they can pose a clinical dilemma because symptoms tend to be nonspecific. Conventional radiographs may demonstrate some causes of hip pain, such as stress fractures and degenerative joint disease. Magnetic resonance imaging (MRI) of the hip has proven valuable in the diagnosis of radiographically occult osseous abnormalities and periarticular soft-tissue disorders such as stress fractures, avulsion injuries, musculotendinous abnormalities, and bursitis. Conventional MRI has been less useful in the evaluation of intra-articular lesions, including acetabular labral tears, intra-articular loose bodies, and cartilage lesions. Visualization of intra-articular structures and their abnormalities can be improved by injection of diluted gadolinium, which distends the capsule and leaks into labral tears. This article focuses on the use of conventional radiography and MRI in recreational and professional athletes with painful hip joints. Where possible, MRI is compared with other diagnostic modalities such as bone scan and computed tomography.

MR Imaging of Osteonecrosis of the Femoral Head with Rapidly Destructive Coxarthrosis

Purpose : In this study, we investigated the magnetic resonance (MR) imaging characteristics of rapidly destructive coxarthrosis (RDC) caused by osteonecrosis of the femoral head. Material and Method : We reviewed 11 hip MR images (10 patients) of osteonecrosis of the femoral head with RDC. MR findings of 11 RDC were compared with those of Ficat stage IV osteonecrosis of the femoral head as a control. Results : The MR findings of osteonecrosis, involving the entire femoral head, bone marrow edema in the acetabulum, intraarticular loose bodies on the inferomedial portion of the hip joint, and synovial proliferation were significant in RDC as compared with those of osteonecrosis of the femoral head only. Conclusion : Distinct findings of MR imaging in conjunction with plain radiographs could be used to facilitate diagnosis, treatment, and prognosis in RDC.

MR findings in knee osteoarthritis.

Knee osteoarthritis (OA) is a leading cause of disability. Recent advances in drug discovery techniques and improvements in understanding the pathophysiology of osteoarthritic disorders have resulted in an unprecedented number of new therapeutic agents. Of all imaging modalities, radiography has been the most widely used for the diagnosis and management of the progression of knee OA. Magnetic resonance imaging is a relatively recent technique and its applications to osteoarthritis have been limited. Compared with conventional radiography, MR imaging offers unparalleled discrimination among articular soft tissues by directly visualizing all components of the knee joint simultaneously and therefore allowing the knee joint to be evaluated as a whole organ. In this article we present the MR findings in knee OA including cartilage abnormalities, osteophytes, bone edema, subarticular cysts, bone attrition, meniscal tears, ligament abnormalities, synovial thickening, joint effusion, intra-articular loose bodies, and periarticular cysts.

Diagnostic arthroscopy of the hip joint

Refinement of diagnosis of hip disorders with the possibility of adding minimally invasive surgical procedures. Hip symptoms and effusions not yet diagnosed. Disorders where a decision has to be taken whether to continue conservative care or to proceed with surgery. Intraarticular loose bodies. Labral lesions. Biopsies to establish a diagnosis. Synovial diseases. Localized articular cartilage defects. Purulent arthritis. Recent fracture of acetabulum. Advanced osteoarthritis. Impossibility to distract the joint. Supine. Arthrography for imaging of labrum and femoral head. Joint distension. 3-portal technique for arthroscopy of the central compartment of the joint under traction on a fracture table. 2-portal technique for viewing of the peripheral compartment without traction. Both techniques make use of 30° and 70° arthroscopes. Between October 1997 and end of 2000, we performed 60 hip arthroscopies: 34 of the central and peripheral compartments, 16 of only the central and ten of only the peripheral compartment. Besides synovial reactions in all, 15 of 33 hips with early or moderate osteoarthritis showed additional intraarticular lesions. These findings justified an early total hip replacement in six patients. In four out of six patients with unclear hip symptoms, a final diagnosis could be established. In another five patients the diagnosis could be confirmed (4× chondromatosis, and 1× free body). In five patients indication for correctional osteotomy was validated and in one rejected due to advanced articular cartilage damage. Complications: transient hypoesthesia (4×), superficial cartilage damage (7×), instrument breakage (2×), small labral tears (4×), soft tissue edema and early termination of operation (2×).

SURGICAL CORRECTION OF THE SNAPPING ILIOPSOAS TENDON IN ADOLESCENTS

There have been very few reports regarding symptomatic snapping of the iliopsoas tendon, and none of those reports have dealt exclusively with an adolescent population. We report our experience with the surgical treatment of this entity in a group of patients who had an average age of fifteen years. Nine adolescent patients (eleven hips) underwent fractional lengthening of the iliopsoas tendon at the musculotendinous junction because of persistent painful snapping of the hip. A modified iliofemoral approach to the iliopsoas tendon was used. The diagnosis in all cases was made on the basis of the history and a physical examination. Plain radiographs were made for all patients to rule out an osseous intra-articular loose body. Follow-up consisted of personal interviews and physical examinations performed at least two years postoperatively. Preoperatively, all patients had audible snapping with pain localized to the anterior part of the groin. The average duration of symptoms was 2.3 years. Prior to the onset of symptoms, all but one of the patients had been involved in competitive athletic activities. Postoperatively, all patients were able to return to the preoperative level of activity without subjective weakness. The average duration of postoperative follow-up was four years. Hip-flexion strength was noted to be nearly equal to that on the contralateral side. All patients reported that they would have the operation again under similar circumstances. One patient had recurrent snapping but stated that it was less frequent and less painful than the preoperative snapping. Two patients had transient sensory loss in the anterolateral aspect of the thigh. We conclude that fractional lengthening of the iliopsoas tendon at the musculotendinous junction is an effective and safe approach for adolescent patients with persistent symptomatic snapping of the iliopsoas tendon that is unresponsive to conservative measures.

Ultrasound of the elbow

This article describes the use of ultrasound (US) in the evaluation of the elbow. US is able to visualize several abnormalities affecting tendons, muscles, ligaments and bursae around the elbow joint as well as to delineate the nature of soft-tissue swelling, such as a space-occupying lesion or synovial enlargment. Occult fractures, osteophytes and intra-articular loose bodies can be depicted with this technique as well. At the cubital tunnel, US allows accurate imaging of the ulnar nerve and to document changes that occur in compressive syndromes. Over other imaging modalities, US offers several key advantages, including cost effectiveness, availability and ability to perform a dynamic examination of tendon movement and joint motion. With continued experience, it is likely that the use of US will increase further with regards to evaluation of soft-tissue abnormalities of the elbow.

Postoperative temporomandibular joint diagnosis

Postoperative management of patients suffering from symptoms of the temporomandibular joint does not differ considerably from the one of preoperative examination protocols. Knowledge of previous surgery helps to plan patient work-up and to interpret normal postoperative findings (eminectomy, discectomy, susceptibility artefacts from metallic residues...) and typical complications (intraarticular loose bodies, dislocations, avascular necrosis, foreign body granulomatous reactions) appropriately.

Ultrasound of the elbow.

Ultrasonography (US) is an efficient alternative to magnetic resonance (MR) imaging for evaluation of soft tissues of the elbow. US is able to diagnose several abnormalities affecting tendons, muscles, ligaments and bursae around the elbow joint. In cubital tunnel syndrome, US identifies ulnar nerve abnormalities and extrinsic lesions that may cause nerve entrapment. Occult fractures, osteophytes and intra-articular loose bodies can also be imaged. In para-articular swelling, US is able to assess the presence of capsular and synovial processes and to differentiate them from soft tissue tumors. Key advantages of this technique include cost-effectiveness, availability and ability to perform a dynamic examination.

Ultrasound of the knee.

Ultrasound is emerging as a viable imaging modality in the diagnosis and assessment of the musculoskeletal system. Advantages of ultrasound include its easy availability and multiplanar capability, as well as economic advantages. Unlike magnetic resonance imaging, ultrasound demonstrates the fibrillar microanatomy of tendons, ligaments and muscles, enhancing its diagnostic capability. The ability to compress. dynamically assess structures and compare easily with the contralateral side is advantageous. The patient's exact point of clinical tenderness can be correlated with underlying anatomical structures and associated pathology. The main strength of knee ultrasound is the assessment of para-articular disease. The specific structures best suited for ultrasound assessment include tendons, muscles and ligaments, as well as periarticular soft tissue masses. Joint effusions, synovial thickening, bursal fluid collections, intra-articular loose bodies, ganglion cysts, ligament and tendons tears, tendonitis and occult fractures can be diagnosed. With experience, ultrasound is a time-efficient, economical imaging tool for assessment of the knee.

Snapping plicae associated with radiocapitellar chondromalacia

Purpose: Painful snapping of the elbow joint is usually attributed to intra-articular loose bodies, instability, or medial dislocation of the triceps muscle over the medial epicondyle. We report our experience with 14 patients who were treated arthroscopically for snapping elbow that was found to be caused by hypertrophic synovial folds associated with radiocapitellar chondromalacia. Type of Study: Case series. Methods: The records of 14 patients who were treated arthroscopically for painful snapping elbows caused by intra-articular plicae were reviewed. There were 6 women and 8 men with an average age of 36 years (range, 27 to 48 years). Nine patients had had some type of trauma to the joint. Four patients had been previously diagnosed with lateral epicondylitis and 5 with intra-articular loose bodies. The average time from initial onset of symptoms to treatment was 13 months (range, 8 to 36 months). Average follow-up was 24 months (range, 6 to 66 months). Results: All patients complained of painful snapping in the posterolateral or anterolateral aspect of the elbow. The snapping occurred between 90° and 110° of flexion with the forearm in pronation. In 7 patients, the snapping was reproducible by passively flexing the pronated elbow, which we refer to as the flexion-pronation test. At the time of arthroscopic surgery, all patients had a thickened synovial plica that would snap back and forward over the radial head, usually associated with a chondromalacic area on the radial head. Twelve patients had complete relief of their snapping after surgery. One patient in whom there was associated posterolateral rotatory elbow instability did not improve. One patient became asymptomatic for 4 years but then had recurrence of her symptoms, which persisted despite 2 subsequent arthroscopies. Conclusions: The presence of synovial plicae in the radiocapitellar joint must be considered in the differential diagnosis of painful snapping elbow. Arthroscopy confirms the diagnosis and allows excision of the plica.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 491–495

Detection of Intraarticular Bodies of the Elbow with Saline Arthrosonography

AIM: To assess whether ultrasound with intraarticular injection of saline increases the detection of intraarticular bodies of the elbow.SUBJECTS AND METHODS: Twelve patients (age range 21–42 years, mean 29 years; 8 male, 4 female) referred over a 2-year period with an equivocal history of elbow locking and plain radiographs had a joint injection of at least 12ml of sterile saline during ultrasound examination. No patient had a joint effusion before injection. Surgical correlation was available in six patients.RESULTS: Ten patients had intraarticular bodies but these were demonstrated only after joint injection in six patients. Arthroscopy performed in six patients confirmed intraarticular bodies in five. Radiographs were falsely positive in one and falsely negative in seven patients.CONCLUSION: Joint injection improves the sonographic evaluation and conspicuity of small and radiographically occult intraarticular loose bodies in the clinically equivocal elbow. The procedure is simple, quick, well tolerated and reproducible. Miller, J. & Beggs, I. (2001).Clinical Radiology56, 231–234.