Subchondral Cystic Changes Research Articles

Outcomes of ankle arthrodesis in adult patients with ankle osteoarthritis in Kashin-Beck disease.

We retrospectively evaluated the characteristics of these patients and the effectiveness of ankle arthrodesis in the treatment of ankle arthritis caused by Kashin-Beck disease (KBD). A retrospective study of KBD patients with ankle osteoarthritis who underwent ankle arthrodesis between December 2012 and January 2022 was performed. A total of 46 patients were included. The general characteristics, clinical manifestations and imaging features of the patients were recorded and summarized. measured using the VAS score, and ankle function was assessed by the AOFAS ankle-hindfoot score. Multiple subchondral cystic changes were found in 42(91.3%) patients. The VAS scores for both resting and weight-bearing conditions were 6.28 ± 1.30 vs. 2.09 ± 1.12 (P < .001) and 6.87 ± 1.01 vs. 2.17 ± 0.98 (P < .001), respectively. The AOFAS scores were 59.17 ± 5.50 and 88.39 ± 1.42, respectively (P < .001). The subchondral multiple cystic transformation of the ankle KBD has a certain suggestive role.Arthrodesis is an effective method to reduce ankle pain and improve ankle function in KBD patients with ankle osteoarthritis.

Sonographic Features of a Medial Subtalar Coalition and Implications for Diagnosis and Treatment.

A 21-yr-old man presented with progressive right medial foot pain. Symptoms began 1 yr prior and were described as aching, stiffness, worse after prolonged standing, but improved with rest. There was no associated weakness, numbness, or inciting mechanical trauma. Physical examination of the right foot showed mildly reduced eversion and inversion and moderately reduced pronation and supination. The medial foot was tender to palpation without evidence of swelling. Strength and sensation were intact along the L2-S1 distributions. Foot radiographs suggested a subtalar coalition (Fig. 1A). This was confirmed on computerized tomography (Figs. 1B, C). Ultrasound was used to visualize the right subtalar joint (Fig. 2A). A contralateral comparison was also obtained (Fig. 2B). Kenalog (40 mg/ml) was injected with excellent arthrogram effect via a sonographically guided, out of plane, posterior to anterior walk down technique. One-month after injection, the patient reported 80% relief in pain.FIGURE 1: A–C, Lateral ankle radiograph, computerized tomography, and 3D reconstruction of the right subtalar joint. Relevant bony structures are identified and include the talus (abbreviated as “tal”), calcaneus (“cal”), and tibia (“tib”). Lateral ankle radiograph demonstrates subtle irregularity along the middle subtalar joint with small, hypertrophic bone formation. Computerized tomography and 3D reconstruction of the right subtalar joint demonstrate evidence of a fibrous or cartilaginous coalition associated with mild to moderate degenerative subchondral cystic change and sclerosis.FIGURE 2: A, Ultrasound image in the coronal plane with a GE Logiq E device using a linear (13–5 MHz) array transducer revealed a reduced right medial subtalar joint with an irregular, pointed joint line appearance consistent with a subtalar coalition. B, A normal contralateral comparison of the left talocalcaneal joint was obtained for comparison.The subtalar joint normally permits foot pronation and supination. Due to closed chain kinetics, the leg normally internally rotates when the foot is in stance and externally rotates during toe-off. In subtalar coalition, this torque converter movement is lost because of joint rigidity, increasing stress on neighboring structures.1,2 Patients may present with rigid pes planus and medial foot pain during periods of increased physical activity. Plain radiographs are first line for evaluation, but direct visualization is difficult because of the complex anatomy of the joint.3,4 Computed tomography has a limited ability to assess adjacent soft tissues. Ultrasound provides excellent resolution of periarticular soft tissue, minimizes exposure to radiation, and maximizes patient comfort. In fibrous coalition, ultrasound demonstrates reduced medial joint space with irregular, hypoechoic tissue.5,6 In osseous coalition, ultrasound demonstrates a smooth, continuous, hyperechoic structure representing disappearance of the joint space.5,6 Ultrasound can confirm suspicion of coalition and allows for dynamic evaluation and therapeutic intervention. LEARNING POINTS Subtalar coalition should be considered as a cause of medial ankle and foot pain in adolescents with restricted ankle motion and flat feet. Direct visualization of the subtalar joint via standard foot radiographs can be difficult, and ultrasound can be especially helpful for dynamic evaluation and therapeutic intervention.

Radiographic Assessment of the Popliteal Lymph Node to Aid the Differentiation of Canine Stifle Osteosarcoma From Moderate to Severe Stifle Degenerative Joint Disease

Degenerative joint disease of the stifle is a common canine osseous pathology. Early degenerative changes may show mild mineral proliferation of periarticular margins with soft tissue, resulting in joint distension. If the joint is chronically unstable, osseous changes become more complex. Moderate to severe stifle degenerative disease then transitions to a combination of bony proliferation and resorption as subchondral cystic changes develop. The radiographic descriptions of moderate to severe degenerative disease overlap with those of subtle aggressive disease. If this occurs in a location prone to primary bone tumors, like the distal femur, radiographic interpretation becomes difficult. The aim of this study was to evaluate the utility of objectively assessing the popliteal lymph node size and shape on radiographs to differentiate moderate to severe stifle degenerative joint disease from distal femoral or tibial osteosarcoma. Stifle radiographs were acquired for evaluation of pelvic lameness localized to the stifle joint. Dogs with moderate to severe degenerative stifle joint disease were radiographed at 3 time points: prior to surgery for a tibial plateau leveling osteotomy (103), immediately postoperation (103), and at a recheck 6-8 weeks postsurgery (62). Dogs with osteosarcoma were radiographed only at time of diagnosis (42). Length and width gross popliteal lymph node measurements and a ratio of long axis to short axis were compared between groups using nonparametric analysis. No significant difference was determined using a long axis to short axis ratio for the popliteal lymph node to differentiate moderate to severe stifle degenerative joint disease and osteosarcoma (P = .290). The gross measurements of the long axis and short axis of the popliteal lymph node for dogs with osteosarcoma were significantly greater than the degenerative joint disease groups (P = .017, P = .000). Thus, evaluation of a long axis to short axis ratio for popliteal lymph nodes does not provide a clinically useful objective measure in differentiating peristifle osteosarcoma from moderate to severe degenerative disease of the stifle joint. The length and width of the popliteal lymph node differed significantly; however, the clinical difference is minimal.

Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection.

Osteomyelitis is inflammation of the bone caused by an infectious organism, and is a difficult clinical problem. The pathophysiology, imaging, and classification of osteomyelitis are challenging, varying with the age of the patient (child versus adult), the chronicity of the infection (acute versus chronic), and the route of spread (hematogenous versus contiguous focus), as well as the immune and vascular status of the patient and affected region. The two most common classification schemes are those of Lew and Waldvogel, and Cierny and Mader. Brodie's abscess is seen in subacute osteomyelitis, while sequestrum, involucrum, and cloaca are inter-related entities of chronic osteomyelitis. Imaging workup of suspected osteomyelitis should begin with radiographs, although MRI is the most accurate imaging test. Three patterns of T1 signal change have been described in the setting of suspected osteomyelitis including confluent intramedullary, hazy reticular, and subcortical. The confluent intramedullary pattern is most associated with osteomyelitis, while hazy reticular is rarely associated with hematogenous osteomyelitis, and subcortical is not associated with osteomyelitis. It can be challenging to differentiate neuropathic arthropathy from osteomyelitis. Osteomyelitis tends to involve a single bone subjacent to an ulcer or sinus tract. In contrast, neuropathic arthropathy tends to involve multiple bones of the midfoot. Subchondral cystic change, thin rim enhancement of a joint effusion, and the presence of intra-articular bodies are more indicative of a neuropathic joint without infection. Biopsy can play an important role in diagnosis and treatment of osteomyelitis.

Large osteochondral lesions of the femoral condyles: Treatment with fresh frozen and irradiated allograft using the Mega OATS technique

BackgroundThe purpose of this study was to review the clinical results of irradiated fresh frozen osteochondral allografts for large osteochondral defects of the knee using the Mega-OATS technique. MethodsNine patients with a mean age of 32.1±6.6 (18 to 44) underwent Mega-OATS transplantation with irradiated (2.5Mrad), fresh frozen distal femur allograft. Three patients also underwent ACL-reconstruction; one patient a high tibial osteotomy. The underlying indication was osteochondrosis dissecans in four and trauma in five patients. The defect size was 25×25mm in three patients and 30×30 in six patients and the depth ranged from eight to 14mm. All OCD lesions were located on the medial femoral condyle; two of the traumatic lesions were located on the lateral femoral condyle. Clinical outcome was assessed using the Lysholm and IKDC scores. Radiographic incorporation was evaluated using serial radiographs and MR imaging at one year post surgery. All patients were reviewed at three, six, 12, and 24months following surgery. ResultsThe Lysholm (IKDC) score improved significantly (p=0.02 resp. p=0.007) within and between patients during the follow-up period from 40.9 (37) to 90.9 (87.1) at 2years. Radiographic union was observed in all patients at three months; on MR imaging at one year osseous integration was observed in eight patients. Graft subsidence with loss of the overlying cartilage was observed in one and subchondral cystic changes at the implantation side were seen in another patient. ConclusionThe results of this case series suggest that irradiated osteochondral allograft provides significant medium-term clinical improvement in patients treated for large osteochondral lesions of the femoral condyles. Level of evidenceIV, case series

Is Subchondral Acetabular Edema or Cystic Change on MRI a Contraindication for Hip Arthroscopy in Patients With Femoroacetabular Impingement?

Background: The outcome for arthroscopic treatment of femoroacetabular impingement (FAI) can worsen with increasing arthritis. However, there remains a subset of hips with relatively maintained joint space but with acetabular subchondral edema and cystic change with unknown outcome on magnetic resonance imaging (MRI). Purpose: (1) To correlate MRI findings of subchondral acetabular edema/cystic change with arthroscopy grading of articular cartilage and (2) to determine whether postoperative outcome was worse for patients with subchondral edema/cystic change compared with a matched control group. Study Design: Cohort study; Level of evidence, 3. Methods: The records of all patients who underwent arthroscopic hip surgery for FAI at a single institution between 2007 and 2013 were reviewed for subchondral edema/cyst on preoperative MRI. Lesions were characterized by grade using an established classification system and were correlated with arthroscopic articular cartilage changes. A matched cohort of patients without evidence of subchondral edema or cyst was identified. Minimum 2-year outcomes were compared using prospectively collected Hip Outcome Score (HOS) activities of daily living and sport subscales as well as the modified Harris Hip Score (mHHS). Results: Overall, 104 patients were included. Thirty-six patients (18 men, 18 women) with a mean age of 41 years (range, 19-67 years) had subchondral edema, with or without the presence of cystic acetabular changes, at minimum 2-year follow-up (range, 24-60 months). Two patients who underwent total hip replacement were excluded in the outcome score comparison. Thirty-one of 34 patients (91%) had a grade 4 full-thickness cartilage lesion at the time of diagnostic arthroscopy. The mean mHHS was inferior for all patients with subchondral edema/cystic change (79.9 ± 18.7 vs 86.6 ± 12.5; P = .03), and the HOS was also lower (69.1 ± 27.0 vs 79.5 ± 21.4; P = .02). The overall success rate was 67% for all patients with subchondral edema/cystic change compared with 85% in the control group (P = .04). Conclusion: The presence of a subchondral edema with an acetabular cyst on MRI is indicative of a full-thickness cartilage lesion at the time of arthroscopy. These patients have inferior outcomes for arthroscopic treatment of FAI compared with patients with similar age and activity level without MRI subchondral cystic changes.

Is MRI Subchondral Acetabular Edema or Cystic Change a Contraindication for Hip Arthroscopy in Patients with FAI?

Objectives:Arthroscopic treatment for femoroacetabular impingement (FAI) generally has good results, but the outcome can worsen with increasing arthritis, largely defined as joint space narrowing. There remains a subset of hips with maintained joint space but with subchondral edema and cystic change of the acetabulum on MRI, with unknown outcome. Therefore, the purpose of this study was (1) to determine if postoperative outcome was worse for patients with subchondral edema on preoperative MRI compared to a matched control group and (2) to identify risk factors on MRI leading to inferior outcome.Methods:A review of patients who underwent arthroscopic hip surgery for FAI between 2007 and 2013 identified 530 patients. Of these, 39 patients had evidence of subchondral edema or subchondral cyst on the preoperative MRI with maintained joint space on preoperative radiographs. Lesions were characterized by grade, location and type using an established radiographic MRI classification system. A matched cohort of patients without evidence of subchondral edema or cyst was identified, and 2:1 matching was based on patient age, surgeon, surgery year within one year, surgical procedure, Tegner activity score, and Tonnis grade osteoarthritis changes on preoperative x-ray. Outcome was compared using the Hip Outcome Score and Modified Harris Hip Score between the two groups. Risk factors were then analyzed for type of lesion, grade and location of bone marrow lesion.Results:Thirty-nine patients (20 males, 19 females) showed preoperative MRI evidence of subchondral edema, and were followed for a mean of 23 months postoperatively (range, 12 - 60 months). Patients had an average age of 41 years (range, 19 - 67) and a preoperative Tegner score of 3.8 (range, 1 - 9). 87% of patients with subchondral cystic change had evidence of a grade IV full thickness cartilage lesion at the time of hip arthroscopy. Average Modified Harris Hip Scores were inferior for the subchondral group (79.9 ± 18.7) compared to the control group (86.6 ± 12.5; p = 0.027). In addition, Sport sub-scales of the Hip Outcome Score showed significantly lower scores for the subchondral group for both score (69.1 ± 27.0 vs. 79.5 ± 21.4, p = 0.018) and rating (66.7 ± 27.5 vs. 78.0 ± 20.8, p = 0.044). No radiographic risk factors, including type, location, or size of lesion were significant predictors of outcome. Two patients in the subchondral group were later converted to a total hip replacement.Conclusion:The presence of a subchondral acetabular cyst on MRI is indicative of a full thickness cartilage lesion at the time of arthroscopy. These patients have inferior outcomes for arthroscopic treatment of FAI compared to patients with similar age and activity level without MRI subchondral changes. Therefore, we recommend caution with consideration of hip arthroscopy in this patient subset.

Fishtail deformity--a delayed complication of distal humeral fractures in children.

Concavity in the central portion of the distal humerus is referred to as fishtail deformity. This entity is a rare complication of distal humeral fractures in children. The purpose of this study is to describe imaging features of post-traumatic fishtail deformity and discuss the pathophysiology. We conducted a retrospective analysis of seven cases of fishtail deformity after distal humeral fractures. Seven children ages 7-14years (five boys, two girls) presented with elbow pain and history of distal humeral fracture. Four of the seven children had limited range of motion. Five children had prior grade 3 supracondylar fracture treated with closed reduction and percutaneous pinning. One child had a medial condylar fracture and another had a lateral condylar fracture; both had been treated with conservative casting. All children had radiographs, five had CT and three had MRI. All children had a concave central defect in the distal humerus. Other imaging features included joint space narrowing with osteophytes and subchondral cystic changes in four children, synovitis in one, hypertrophy or subluxation of the radial head in three and proximal migration of the ulna in two. Fishtail deformity of the distal humerus is a rare complication of distal humeral fractures in children. This entity is infrequently reported in the radiology literature. Awareness of the classic imaging features can result in earlier diagnosis and appropriate treatment.

Glenohumeral Chondrolysis Associated with Use of an Intra-Articular Pain Pump Delivering Local Anesthetics Following Manipulation Under Anesthesia

Glenohumeral chondrolysis is a devastating condition characterized by rapid dissolution of the articular cartilage surfaces of the glenoid and the humeral head. Patients typically present with a painful stiff joint, and radiographs demonstrate joint space narrowing and subchondral cystic changes. Because most cases of glenohumeral chondrolysis have occurred following arthroscopic shoulder surgery, the term “post-arthroscopic glenohumeral chondrolysis” (PAGCL) has been used to describe this condition. Several causative factors have been implicated, including suture anchors that are prominent or that become loose1, excessive intra-articular use of thermal heat2-4, and intra-articular pain pump (IAPP) catheters delivering local anesthetics5-10. Most of the patients described developed glenohumeral chondrolysis following arthroscopic stabilization procedures in which one or more suture anchors were employed, with or without adjunctive use of thermal heat, and in which an IAPP was placed at the conclusion of the procedure to deliver local anesthetics for postoperative analgesia. To the best of our knowledge, glenohumeral chondrolysis developing after the use of an IAPP and without arthroscopy has not been described previously. We report four cases of glenohumeral chondrolysis that occurred following the use of an IAPP delivering either 0.25% or 0.5% bupivacaine with epinephrine for forty-eight to sixty hours after isolated manipulation of the shoulder under anesthesia, without a surgical procedure. In all four patients, the initial treatment, including manipulation and placement of an IAPP (AmbIT; Sorenson Medical Products, West Jordan, Utah), was done elsewhere by the same orthopaedic surgeon between March 2006 and August 2007. One of the four patients was treated with a subsequent prosthetic shoulder arthroplasty by another surgeon prior to referral to the senior author (S.S.H.). Each of the four patients in this series was informed that data concerning his or her case were submitted for publication, and verbal …

The Use Osteochondral Allograft in the Treatment of a Severe Femoral Head Fracture

This study reviews the second case in the literature involving the use of frozen osteochondral allograft to reconstruct a femoral head fracture-dislocation. The case involved significant, unreconstructable damage to the weightbearing area of the femoral head in an 18-year-old male. Clinical and diagnostic imaging follow up at 46 months revealed that despite magnetic resonance imaging and radiographic evidence of progressive arthrosis in the hip, including subchondral cystic change in the femoral head and localized cartilage loss in the acetabulum and femoral head, the patient had excellent function with no complications (Harris hip score 100, hip dysfunction and osteoarthritis outcome score 62, musculoskeletal function assesment score 22, SF-36 score 81). The use of osteochondral allograft may serve as a useful tool for the orthopaedic surgeon faced with an unreconstructable femoral head fracture-dislocation in a young patient.

Internal impingement: findings on magnetic resonance imaging and arthroscopic evaluation.

The purpose of this study was to examine preoperative shoulder magnetic resonance imaging (MRI) and intraoperative arthroscopic findings in throwing athletes with a clinical diagnosis of internal impingement. Retrospective review. A retrospective review of the surgical indications for 769 shoulder arthroscopic procedures performed from 1997 to 2000 revealed 9 throwing athletes with a diagnosis of severe internal impingement. Each had failed treatment that included a minimum of 3 months of rehabilitation. Preoperative MRIs in all 9 were read by a fellowship-trained musculoskeletal radiologist blinded to the operative findings. Findings at arthroscopy were culled from the operative reports. On both MRI and at arthroscopy, all 9 athletes had posterosuperior labral lesions, 1 had a humeral head articular cartilage lesion, and 1 had a SLAP lesion. Additional findings on MRI included humeral head edema, subchondral cystic changes, posterosuperior glenoid sclerosis, and rotator cuff tendonopathy predominantly in the infraspinatus. At arthroscopy, there were additional findings of articular-sided partial rotator cuff tears not shown on MRI. Both MRI and arthroscopic findings described labral and humeral head articular cartilage lesions. These findings may be indicative of internal impingement in throwing athletes. Level III, diagnostic.

A 57-Year-Old Man With Osteoarthritis of the Knee

DR SHIP: Mr V is a 57-year-old man who has had knee pain for at least 30 years. He lives in Boston with his wife, with whom he owns and runs a business. He has managed care insurance and sees his primary care physician, Dr P, at Beth Israel Deaconess Medical Center. Mr V dates the onset of his left knee problems to a soccer injury at age 26. He was diagnosed with rupture of 2 ligaments and underwent a course of physical therapy. His pain diminished over time, but he was aware that his left knee was never again at “100%.” He continued his active athletic life, which included soccer, bicycle racing, and running at least 3 times per week. About 15 years ago, however, pain in his left knee recurred and became severe enough that he stopped running and moved largely to long-distance cycling. Thirteen years ago he underwent an arthroscopic debridement. This improved his level of function and decreased his pain for approximately 2 years, but symptoms subsequently recurred. He has since had several courses of physical therapy but has found the recommended exercises to be so painful that he could not complete them. Despite persistent, often severe, knee pain, Mr V remains a very active long-distance (“ultra marathon”) bicyclist, cycling in qualifier events and races of more than 700 miles (1120 km). He estimates his annual cycling distance to be about 7000 miles (11200 km), a number that he views as a marked reduction from his previous distance of between 10000 and 12000 miles (16000-19200 km) annually. In addition, he continues to lift weights and work out regularly. His knee pain has progressed, however, so that he often has severe pain after standing for long periods as he needs to during work, and he is unable to garden because of pain brought on by bending his left knee. He was prescribed naproxen, 1000 mg/d, but finds that 500 mg/d is effective at “helping” with the pain, and he is hesitant to take the higher dose. Other than knee pain, Mr V is very healthy. He has no other medical problems and has had no other surgical procedures. He follows a vegetarian diet and neither smokes nor drinks. In addition to the naproxen, he takes garlic pills. He is not allergic to any medications. There is no family history of osteoarthritis. On physical examination, Mr V was 5’10” tall and weighed 155 lb. His left knee appeared slightly larger than his right but had no erythema or warmth. When standing, he had varus deformities of both knees and a slightly antalgic gait. Range of motion on the left knee was 5° to 120° compared with 5° to 140° on the right. Collateral and cruciate ligaments were stable. Crepitus was noted. There was a moderate effusion in the left knee and a palpable semi-membranous bursa. There was no distal neurovascular compromise in either knee. Hip range of motion was full and pain-free bilaterally. Radiographs of the left knee in 1999 revealed marked tricompartmental osteoarthrosis with prominent osteophyte formation and severe joint space narrowing. The medial joint space was the most narrowed compartment. There was subchondral sclerosis, most prominently also in the medial hemijoint space, and lateral subluxation and varus angulation were noted. Significant subchondral cystic changes were identified involving the tibial plateau centrally as well as the medial femoral condyle, thought to represent geode formation from osteoarthrosis. Total knee replacement has been offered to Mr V, but different orthopedists have varied in their recommendations regarding the timing of the surgery. Mr V wonders whether and when he should plan to undergo knee replacement and how long he can expect the prosthesis to last.