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OBJECTIVE: To describe the CT and MR imaging appearance of both osseous and extraosseous manifestations of melorheostosis. DESIGN AND PATIENTS: We retrospectively reviewed the CT (n=7) and/or MR imaging findings (n=12) of 17 patients with characteristic radiographic findings of melorheostosis (undulating cortical hyperostosis with marked uptake on radionuclide bone scintigraphy). RESULTS: CT and MR imaging revealed cortical hyperostosis as high attenuation and low signal intensity on all MR pulse sequences, respectively. Encroachment on the marrow space was seen in all cases resulting from endosteal involvement. Thirteen patients demonstrated 14 soft tissue masses with infiltrative margins in 80% of cases and seven showed extensive mineralization on CT or MR imaging (low intensity on all pulse sequences). Seven soft tissue masses were predominantly nonmineralized with intermediate signal intensity on T1-weighted and intermediate to high signal on T2-weighted MR images corresponding to vascularized fibrous tissue with variable collagen content pathologically. Enhancement after intravenous gadolinium was seen in all patients imaged with soft tissue masses (n=2). Two patients demonstrated muscle atrophy resulting from nerve involvement. CONCLUSIONS: The osseous abnormalities in melorheostosis are identical on advanced imaging and radiographs. Mineralized or nonmineralized soft tissue masses should be recognized as another manifestation of this disease as opposed to a more ominous finding, making biopsy unwarrranted.

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An intraarticular, dorsal, proximal epiphyseal stress fracture (Salter-Harris III) of the first metatarsal was identified in a 14-year-old boy. Successful fracture healing was achieved with a rocker sole shoe modification and activity limitation.

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Congenital tarsal coalition is a diagnosis that is often overlooked in young patients who first present with foot and ankle pain. Calcaneonavicular and talocalcaneal coalitions are encountered most frequently; fusion at other sites is much less common. Tarsal coalitions may be osseous, cartilaginous, or fibrous. Calcaneonavicular coalitions are readily detected on oblique radiographs. Radiographic confirmation of talocalcaneal coalition is more difficult than for fusion at other locations, although several secondary radiographic signs may indirectly suggest the diagnosis. Computed tomography (CT) and magnetic resonance (MR) imaging are invaluable for assessment of tarsal coalitions because they allow differentiation of osseous from nonosseous coalitions and because they depict the extent of joint involvement as well as secondary degenerative changes, features of vital importance in surgical planning. Short-inversion-time inversion recovery MR images may reveal bone marrow edema along the margins of the abnormal articulation, an important clue to the diagnosis. Moreover, CT or MR imaging may be required to confirm the diagnosis of talocalcaneal coalition when radiographic findings are equivocal. Because the diagnosis of tarsal coalition is often not entertained by the clinician ordering a CT or MR imaging examination, multiplanar imaging of the ankle and hindfoot is required.

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In this study, 92 primary total hip arthroplasties were performed in 83 patients using a porous-coated, dual-radius, cementless, acetabular component. All hips underwent line-to-line dome reaming with press-fit implantation that was judged to have complete bone contact. This acetabular shell provides a 1-mm oversized peripheral rim, which adds excellent initial stability while allowing complete bone contact in all hips. No fractures occurred. In 83% of hips, adjunctive screw fixation was not necessary. At a minimum of 4 years, follow-up, there were no revisions, no acetabular migration, one case of acetabular erosion consistent with osteolysis, and the average Harris Hip Score was 95. The design features of this new acetabular component have provided excellent fixation with complete initial bone contact, resulting in satisfactory intermediate clinical and radiographic results. The design provides excellent peripheral stability and complete bone contact.

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A 39-year-old woman sustained a forced dorsiflexion injury to the left great toe while pivoting to the right during tennis activity. Posteromedial ankle pain was reproduced with active plantarflexion and passive dorsiflexion of the great toe and, to a smaller extent, the lesser toes. Symptoms persisted for 9 months despite nonoperative treatment. Magnetic resonance imaging 5 months after injury revealed evidence of fluid surrounding the flexor hallucis longus (FHL) tendon. Operative findings 9 months after injury included scar tissue and tenosynovitis of the FHL and flexor digitorum longus tendon sheaths, with impingement of distal FHL muscle fibers and a longitudinal split tear (partial rupture) of the FHL tendon. Tenolysis, tenosynovectomy, excision of the distal muscle fibers, and repair of the partial tendon rupture were performed, resulting in resolution of symptoms. Partial rupture of the FHL tendon as a single-impact injury, or in activity other than ballet, has not been documented previously.

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MR imaging is sensitive in the detection of occult stress and posttraumatic fractures in and around the knee joint. In some patients, the pain from these bony injuries can mimic that of meniscal tears. The abnormality of the bone may explain completely the patient's symptoms and obviate the need for any further work-up. The types of injuries detected by MRI include bone bruises, stress or insufficiency fractures, and osteochondral fractures. Bone bruises or contusions are characterized by a diffuse or localized pattern of low signal intensity on T1-weighted images without a defined fracture. Blood, edema, hyperemia, and perhaps microfracture of the trabeculae may all contribute to the marrow signal alterations. Anterior cruciate ligament injuries often are accompanied by a characteristic bone contusion pattern, such as hemorrhage or edema in the posterior aspect of the lateral tibial plateau, as well as the anterior aspect of the lateral femoral condyle.

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Twenty-five patients had Russe anterior corticocancellous bone-grafting between 1973 and 1984 for twenty-six symptomatic established non-unions of the scaphoid. The mean duration of follow-up was eleven years (range, seven to eighteen years). Twenty-one (81 per cent) of the twenty-six scaphoid bones united. We developed two rating scales to evaluate the results of the operation. One scale, based on objective findings, included the radiographic appearance of the wrist, the range of motion, and strength; the other scale, based on subjective findings, comprised function, pain, perception of a decrease in performance because of limitation of motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had a malunion of the scaphoid in which the lateral intrascaphoid angle was more than 45 degrees convex dorsally between the proximal and distal poles (a so-called flexion or humpback deformity, which results in extension of the proximal fragment of the scaphoid at the radiocarpal joint) with the results in patients who had no such deformity. The lateral intrascaphoid angle was more than 45 degrees in thirteen (50 per cent) of the twenty-six wrists. Although the difference in the objective results between the wrists that had a malunion and those that did not have a malunion was highly significant (p = 0.001), there was no significant difference in the subjective results between the two groups, including satisfaction of the patient (p = 0.39). Twenty-three patients (92 per cent) returned to full-time employment and twenty-two (88 per cent), to sports activities. Twenty-three patients (92 per cent) reported that they had pronounced relief of pain and that the procedure had improved their quality of life. The presence of this deformity of the scaphoid after bone-grafting for a symptomatic non-union was not predictive of a poor long-term subjective outcome.

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CT has become the imaging modality of choice in most acute and chronic injuries involving the articular surfaces. Today's technology allows high resolution, fast scanning, and rapid reformatting, all of which contribute to prompt orthopedic evaluation and decision making. Our orthopedic colleagues have come to rely on high-quality CT scans in order to evaluate calcaneal and tibial plateau fractures, stress fractures, osteochondritis dissecans, acute and chronic shoulder trauma, and problems of the painful wrist--especially the distal radioulnar joint.

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From a systematic review of the literature on septic arthritis and our own patient records we found that in a high percentage of cases (20% of those we reviewed) infection of the sternoclavicular joint leads to an abscess. This appears to be true regardless of the presence or absence of a history of intravenous drug abuse or underlying illness compromising the immune system, and regardless of the responsible organism. The predisposing factors must center on the joint itself. The risk from spread of infection should be considered in management of the uncommon but difficult clinical problem of sternoclavicular septic arthritis.

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This article presents the important anatomic features of the shoulder joint and the abnormalities to which the athlete is most susceptible leading to pain and disability. It also reviews the pertinent elbow anatomy and discusses the radiographic techniques currently employed in diagnosing elbow problems in the athlete, including tomography, arthrography, and computed tomography.

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Ninety-nine anteroposterior and lateral lumbar radiographs taken of men, 18 to 55 years of age, were randomly selected from participants in a population survey of low-back pain. Thirty-one (31%) had never had low-back pain; 44 (44%) had or were having mild low-back pain; and 24 (24%) had or were having severe low-back pain. Three chiropractors assessed 56 radiographic variables, which included determinations of disc space height, vertebral malalignments and subluxations, spondylosis, postural disturbances, relationships among pelvis and spine and other congenital or acquired abnormalities. Interobserver reliability measurements showed that 6 of the 56 variables analyzed produced a high interobserver reliability. Sixteen additional variables showed a fair interobserver reliability. Comparison of the observations made by the chiropractors and a radiologist showed minimal agreement except for disc space height assessments at L3-4 and L4-5. Few of the radiographic variables discriminated between the current or prior history of low-back and leg complaints, although a few variables (most notably disc space narrowing) were statistically associated with back or leg complaints (P = .025). The conclusion was reached that spinal radiographs, whether analyzed by measurements, by a radiologist, or by chiropractors, have minimal value in determining the presence or absence of low-back complaints and, in particular, have no value in epidemiologic studies.

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Pelvic radiographs of 200 consecutive Japanese Oriental patients who were admitted for hip surgery at the Hospital of Kobe University in Japan were compared with those of 199 consecutive American white patients who were admitted for the same purpose to a New England hospital over a similar four and a half-year period between 1972 and 1976. One hundred and fifty-three Japanese Oriental and 157 American white patients had either primary or secondary osteoarthritis. The remainder had other types of hip pathology, such as avascular necrosis, rheumatoid arthritis, and ankylosing spondylitis. The radiographs of five Japanese Oriental and seven American white patients showed evidence of previous Legg-Calvé-Perthes disease, coxa vara, or slipped capital femoral epiphysis. With only two exceptions, the osteoarthritis in the remainder of the Japanese Oriental patients was secondary, caused by antecedent congenital hip disease: twenty-eight had one or two congenitally dislocated hips, ninety-two had acetabular dysplasia, and twenty-six had superolateral osteoarthritis. In contrast, only nine of the American white patients clearly had a diagnosis of acetabular dysplasia, and twenty-six had superolateral osteoarthritis. Twenty-one American white men had a femoral head-tilt deformity. Among the Americans, the largest group (sixty-five patients) had superomedial osteoarthritis. Nine had non-rheumatoid protrusio acetabuli and twenty had axillary or concentric osteoarthritic involvement. The majority of American white patients, therefore, had a type of osteoarthritis that was not seen in the Japanese Oriental patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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In an attempt to diagnose avascular necrosis (AVN) of the patella, a potential complication of the surgical procedure, 99mTc-MDP bone scanning was performed pre- and postoperation in 37 patients treated by 41 total knee arthroplasties. The normal immediate postoperative scan should demonstrate increased radionuclide uptake in the patella when compared to preoperative scans. Decreased uptake was seen in four cases in the early postoperative period. This latter group was believed to be at risk for osteonecrosis and stress fracture of the patella. For this reason, prophylactic restriction of activity was instituted, with subsequent return of normal radionuclide uptake in the patella. Bone scanning provides an effective method of early diagnosis of patients at risk for the development of AVN and secondary patellar fractures following total knee arthroplasty.

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Arthrography is considered extremely safe since reactions to intraarticular contrast media are rare. We have only seen one severe complication in the performance of more than 2,000 arthrographic procedures. To determine the incidence of complications, a questionnaire was sent to 84 radiologists experienced in arthrography. The 57 respondents had performed more than 126,000 arthrographic procedures, and findings of the survey indicate no deaths, three cases of infection, and 61 cases of hives. Other acute reactions included hypotension, seizures, air embolism, and laryngeal edema. Related complications included sterile chemical synovitis, severe pain after the procedure, and vasovagal reactions.

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The technology of digital subtraction image processing was applied as a substitute for conventional arthrographic subtraction techniques in the evaluation of 29 joints in 27 patients. There were 15 total hip replacements, one total knee replacement, eight wrists, three shoulders, and two ankles. Information regarding prosthetic component loosening and ligamentous disruption of carpal bone articulations could be determined with a high degree of accuracy when compared with information gained using conventional radiographic methods. Our results indicate that this method may be a suitable substitute for other arthrographic techniques.

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We aspirated the retrocalcaneal bursa in cadavers to determine the characteristics of bursal fluid. A small amount of clear, viscous fluid was constantly present in the bursa. Leucocyte count was low, and the mucin clot test was good. With the same technique we aspirated the retrocalcaneal bursae of 4 patients. Three had Reiter's syndrome; the bursal fluid was inflammatory, and symptoms promptly resolved after local corticosteroid injection. The fourth patient presented with heel pain; intracellular, positively birefringent crystals were present in the aspirate, consistent with the diagnosis of pseudogout.

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In 1961, the senior author reported 11 members of one family with infantile cortical hyperostosis. Since then, 10 new cases have occurred in this family resulting in a total of 21 cases. The incidence of infantile cortical hyperostosis in this family is as common today as it was two generations ago, and there has been no diminution in the incidence. Several patients with minimal or no clinical symptoms would have gone unrecognized had it not been for the family history of the disorder. On the basis of this study, infantile cortical hyperostosis is inherited as an autosomal dominant with variable penetrance.

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Intraosseous ganglion of the lunate is a relatively rare entity. Two cases are reported, in one of which a communication with the scapholunate joint was demonstrated by polytomography. Curettage and bone grafting resulted in complete relief of pain.

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