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1.  SAPHO Syndrome – A Pictorial Assay 
The Iowa Orthopaedic Journal  2012;32:189-195.
SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome is a distinct clinical entity representing involvement of the musculoskeletal and dermatologic systems. It is well known to rheumatologists because of characteristic skin manifestations and polyarthropathy. However, few reports exist in the orthopaedic literature. It is important to be aware of sAPHO syndrome as it can mimic some of the more common disease entities such as infection, tumor, and other inflammatory arthropathies. Anterior chest wall pain centered at sternoclavicular and sternocostal joints is an important and characteristic clinical finding which can point to its diagnosis. A patient may undergo different diagnostic tests and invasive procedures such as biopsies before a diagnosis is made. Imaging can be helpful by offering a detailed evaluation of the abnormalities. More importantly it helps in revealing subclinical foci of involvement due to the polyostotic nature of the disease. The treatment is mostly nonsurgical. NSAIDS are the first line agents. However multiple new agents are being used for refractory cases. Surgery is reserved to treat complications.
PMCID: PMC3565401  PMID: 23576940
To assess the diagnostic performance of signal changes in Hoffa's fat pad (HFP) assessed on non-contrast-enhanced (CE) MRI in detecting synovitis, and the association of pain with signal changes in Hoffa’s fat pad on non-CE MRI and peripatellar synovial thickness on CE MRI.
The Multicenter Osteoarthritis (MOST) Study is an observational study of individuals who have or are at high risk for knee OA. All subjects with available non-CE and CE MRIs were included. Signal changes in HFP were scored from 0 to 3 in 2 regions using non-CE MRI. Synovial thickness was scored from 0 to 2 on CE MRI in 5 peripatellar regions. Sensitivity, specificity and accuracy of HFP signal changes were calculated considering synovial thickness on CE MRI as the reference standard. We used logistic regression to assess the associations of HFP changes (non-CE MRI) and synovial thickness (CE MRI) with pain from walking up or down stairs, after adjusting for potential confounders.
A total of 393 subjects were included. Sensitivity of infrapatellar and intercondylar signal changes in HFP was high (71% and 88%), but specificity was low (55% and 30%). No significant associations were found between HFP changes on non-CE MRI and pain. Grade 2 synovial thickness assessed on CE MRI was significantly associated with pain after adjustments for potential confounders.
Signal changes in HFP detected on non-CE MRI are a sensitive but non-specific surrogate for the assessment of synovitis. CE MRI identifies associations with pain better than non-CE MRI.
PMCID: PMC3578385  PMID: 23277189
Knee osteoarthritis; synovitis; magnetic resonance imaging; knee pain
The Iowa Orthopaedic Journal  2011;31:219-224.
Infectious spondylodiscitis is an uncommon disease with increasing incidence that typically presents with abnormalities in two adjacent vertebral bodies and the intervening disk. We describe two cases that initially presented with imaging abnormalities in only a single vertebral body. Both patients had a history of lumbar back pain and elevated inflammatory markers, but the lack of classical spondylodiscitis imaging findings led to diagnostic delay and confusion. It is likely that the incidence of atypical presentations of spondy-lodiscitis will increase as the disease incidence increases and imaging is performed at an earlier stage. It is important to recognize the disease early because early diagnosis is the key to preventing serious complications like epidural abscess and spinal cord compression.
PMCID: PMC3215139  PMID: 22096445
CT-guided biopsy is a minimally invasive diagnostic method of evaluating musculoskeletal lesions. Other options include incisional and excisional biopsy with the possibility of intraoperative frozen section. The clinician's decision to order a CT-guided biopsy requires an understanding of the likelihood that this biopsy will affect treatment This requires an understanding of both diagnostic yield and accuracy. Furthermore, the clinical utility of a biopsy is affected by factors other than the yield and accuracy as the clinical setting may render a technically diagnostic biopsy unhelpful.
A retrospective review of the electronic record at an orthopedic oncology referral center identified all patients who had undergone CT-guided percutaneous needle biopsy of mus-culoskeletal lesions after being evaluated by an orthopedic oncologist in clinic over a period of 5 years. 53 CT-guided biopsies of bone lesions and 16 CT-guided biopsies of soft tissue lesions were identified. The diagnostic yield (rate of obtaining tissue from which the pathologist could report a diagnosis) and clinical utility (rate at which biopsy results guided treatment decisions) were calculated and statistically compared.
The overall diagnostic yield of CT-guided bone biopsies was 94% (50 of 53 biopsies) and the clinical utility was 70% (37 of 53 biopsies). In the first 2 years of the study the diagnostic yield was 95% (21 of 22 biopsies) and the clinical utility was 86% (19 of 22 biopsies). In the remaining 3 years the diagnostic yield was 91% (28 of 31 biopsies) and the clinical utility was 58% (18 of 31 biopsies). This decrease in clinical utility over time was statistically significant (p = 0.01). Suspicion of metastasis resulted in a diagnostic yield of 100% (11/11) and a clinical utility of 91% (10/11). Suspicion of primary tumor resulted in a diagnostic yield and clinical utility of 93% (39/42) and 67% (28/42), respectively. This difference in clinical utility was statistically significant (p = 0.02). The diagnostic yield of CT-guided soft tissue biopsies was 75% (12 of 16 biopsies) and the clinical utility was 69% (11 of 16 biopsies). The diagnostic yield was significantly lower for soft tissue biopsy than bone biopsy (p = 0.01). There was no relationship between the rate of diagnostic biopsies and the evaluating pathologist or the location of the lesion within the body.
CT-guided biopsy is useful in the diagnosis of musculoskeletal lesions, however, its clinical utility is substantially lower than its diagnostic accuracy and yield due to a significant rate of diagnostic biopsies that fail to guide treatment, particularly when a primary lesion is suspected. The disparity in clinical utility based on preoperative suspicion of metastasis was even greater in our study than previously shown. CT-guided percutaneous needle biopsy is much more likely to guide treatment in the setting of suspected bone metastasis as opposed to biopsies of suspected primary bone lesions and soft tissue lesions.
PMCID: PMC2958274  PMID: 21045975
The Iowa Orthopaedic Journal  2010;30:182-187.
Facet joint septic arthritis is a rare but severe infection with the possibility of significant morbidity resulting from local or systemic spread of the infection. Pain is the most common complaint on presentation followed by fever, then neurologic impairment. While the lumbar spine is involved in the vast majority of cases presented in the literature, the case presented here occurred in the cervical spine. The patient presented with a three week history of neck and left shoulder pain and was diagnosed by MRI when his pain did not respond to analgesics and muscle relaxants. The only predisposing factor was a history of diabetes mellitus and the infection most likely resulted from hematogenous spread. MRI is highly sensitive in diagnosing septic arthritis and it is the preferred modality for demonstrating the extent of infection and secondary complications including epidural and paraspinal abscesses as seen in this case. Without familiarity with this entity's predisposing factors, clinical symptoms and appropriate lab/ imaging work up, many patients experience a delay in diagnosis. Treatment involves long term parenteral antibiotics or percutaneous drainage. Surgical debridement is reserved for cases with severe neurologic impairment. The incidence of facet joint septic arthritis is increasing likely related to patient factors (increasing number of patients >50 yo, immunosuppressed patients, etc), advancement in imaging technology, availability of MRI, and heightened awareness of this rare infection which is the aim of this case presentation.
PMCID: PMC2958294  PMID: 21045995

Results 1-9 (9)