MRI and ultrasound in the post operative rizarthrosis patient

MRI and ultrasound in the post operative rizarthrosis patient Poster No.: C-2190 Congress: ECR 2012 Type: Educational Exhibit Authors: L. Fernandes, P. Alves, J. Lopes Dias, J. Pereira, R. D. T. 1 2 3 2 1 1 2 2 3 Mesquita, H. A. M. R. Tinto ; Lisbon/PT, Lisboa/PT, Porto/PT Keywords: Musculoskeletal joint, MR, Ultrasound, Imaging sequences, Tissue characterisation DOI: 10.1594/ecr2012/C-2190 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 27

Learning objectives To illustrate the normal and MRI and US findings in the post operative rhizarthrosis patient submitted to trapizectomy and tendon interposition arthroplasty. To specifically define the normal MRI and ultrasound appearances of the tendon interposition. Background Rhizarthrosis is a disabiling degenerative disease that can result in morphological and functional alterations of the trapezium-metacarpal joint and the scaphotrapezial articulation, as well as two lesser articulations, the trapeziotrapezoid and the trapeziometacarpal to the index finger. Fig. 1: Fig. 1 Plain left hand X- ray to demonstrate the presence of trapeziometacarpal osteoarthritis. X-rays show joint space narrowing, sclerosis of subchondral bone and osteophyte presence (black arrow) Page 2 of 27

Predominantly affects middle-aged women and is often bilateral. All patients had an x-ray to demonstrate the presence of trapezio-metacarpal osteoarthritis (X-rays all showed joint space narrowing, sclerosis and osteophyte presence). Table 1-Eaton classification system for trapeziometacarpal arthritis Staging Radiographic Characteristics Stage I Normal or slightly trapeziometacarpal joint widened Normal articular contours Trapeziometacarpal subluxation present up to one third (if of the articular surfasse Stage II Decreased trapeziometacarpal joint space Trapeziometacarpal subluxation present up to one third (if of the articular surface) Osteophytes or loose bodies less than 2 mm in diameter Stage III Further decrease in trapeziometacarpal joint space Subchondral cysts or sclerosis Osteophytes or loose bodies 2 mm or more in diameter Trapeziometacarpal joint subluxation of one third or more of the articular surfasse Page 3 of 27

Stage IV Involvement of the scaphotrapezial joint or less commonly the trapeziotrapezoid trapeziometacarpal joint to the or index finger Ultrasound (US) can detect osteophytosis, and joint space narrowing and the presence of synovitis or synovial cyst related with clinical pain. In the literature there are different types of treatment for the rhizarthrosis: conservative, as the recruitment of NSAIDs, or surgical. If the condiction is not treated, a severe adduction contraction of the thumb and subluxation of the metacarpal joint can develop. Images for this section: Fig. 1: Fig. 1 Plain left hand X- ray to demonstrate the presence of trapezio-metacarpal osteoarthritis. X-rays show joint space narrowing, sclerosis of subchondral bone and osteophyte presence (black arrow) Page 4 of 27

Imaging findings OR Procedure details Surgical Technique Arthroplasty techniques have ranged from simple partial or complete trapizectomy to various implant and ligament interposition reconstructions. These techniques have been generally indicated for stage II or greater disease once the patient failed conservative management. Ligamentous reconstruction and tendon interposition arthroplasty often involves the resection of all or a portion of a wrist tendon. The resected wrist tendon is used as space occupying interposition spacer and may also be used to provide stability to the first metacarpal by placing the tendon through the base of the metacarpal. Many tendons may be harvested for the carpometacarpal arthroplasty procedure, including the palmaris longus, the extensor digitorum and the flexor carpi radialis. Multiple modifications have been published since the original description of this procedure and most use the flexor carpi radialis tendon. Methods and Materials Patients submitted to surgical correction with trapizectomy and tendon interposition during the years 2010 and 2011 were examined with MRI, Ultrasound and plain hand x-rays ( with measurement of space post-trapeziectomy N: #5mm). MRI examinations were done in both 1,5T and 3T machines with a protocol consisting of high resolution T1,T2,DP and DP w/fat SAT images Results MR images of the wrist and hand are obtained in axial, coronal and sagittal planes. T1and T2-weighted axial images are used in virtually all cases, for they provide most of the information necessary to evaluate pathologies of the tendons, their appendages, and adjacent soft tissues. Normal features The normal tendon interposition has the usual low signal intensity appearance of tendons and the normal fibrillar ultrasound structure. Page 5 of 27

Table 2- Normal MR signal features T1 T2 DP Ligament interposition low signal intensity low signal intensity low signal Ligament web low signal intensity low signal / low signal intermediate signal intensity 1ºmetacarpal base low signal intensity intermediate signal intermediate signal intensity intensity Space post- low signal intensity trapeziectomy low signal intensity lowsignal intensity Fig. 2: Fig 2 Axial T1-weighted image through the wrist in a patient who had undergone a ligamentous reconstruction and tendon interposition arthroplasty with complete trapeziectomy shows what appears to be a regenerated flexor carpi radialis tendon (in white oval). The tendon had decreased signal on the T1-weighted images and is normal in size Page 6 of 27

Fig. 4: Fig 4 DP w/fat SAT image through the wrist of the same patient shows the usual low signal intensity appearance of flexor carpi radialis tendon (in white oval). Fig. 5: Fig 5 Coronal DP w/fat SAT image of the same patient shows a normal appearing of flexor carpi radialis tendon ( arrow) with low signal intensity and an unremarkable caliber and the usual low signal intensity appearance in the surgical tendon insertion with no abnormality (in white oval). Page 8 of 27

Fig. 7: Fig:7 DP WI, coronal plane: the normal low signal intensity tendon interposition loop in thesurgical tunnel created at the base of the first metacarpal. There should be no tendon high signal intensity zones, free fluid or cystic lesions associated. Page 10 of 27

Fig. 8: Fig. 8: Coronal DPWI: normal tendon interposition in ints long axis wit the expected low signal intensity inserting on the surgical tunnel at the metacarpal base. Page 11 of 27

Fig. 9: Fig.9 Coronal T1 and axial T2 WI: in this technique the tendon interposition completely fills the trapizectomy cavity (arrows) to prevent the shortening of the first ray of the hand. The cavity has a normal low, slightly heterogenous signal intensity. Fig. 10: Fig. 10 Oblique axial T2WI: the surgical tunnel at the metacarpal base filled with the low signal intensity tendinous loop. Page 12 of 27

Fig. 11: Fig.11 Axial ultrasound image of a normal tendon transfer at the trapizectomy Cavity. Fig. 12: Fig.12 Normal tendon transfer on ultrasound (long axis) : the tendon has the normal fibrillar pattern with no peritendinous thickening or rupture. Patologic features Page 13 of 27

The patient who had undergone an ligamentous reconstruction and tendon interposition arthroplasty may develop intrasubstance changes consistent with tendinosis that may or may not be associated with post operative clinical failure. The trapizectomy site may present non specific soft tissue thickening, free fluid or cysts. All these changes were correlated with the measurements of the first web and trapezial space made on the hand x-rays. MRI also allows the depiction of bone marrow changes in the bone segments of the first web and a semi quantitative evaluation of persistent synovitis that may be responsible for post operative pain and amenable to non surgical intervention. Fig. 13: Fig. 13 Axial ultrasound image of the tendon transfer showing a longitudinal split in the tendon with two "hemi" tendons. Page 14 of 27

Fig. 14: Fig. 14 Axial ultrasound image of the tendon transfer showing fluid surrounding the tendon. Although there was no rupture this patient had pain around the metacarpal base and the trapizectomy site. Page 15 of 27

Fig. 15: Fig. 15 Coronal DPW FAT SAT: slight edema at the metacarpal base (long arrow). The patient had mild pain and disconfort. There was no rupture of the tendon interposition(short arrows) Fig. 16: Fig. 16 Oblique axial DP: the tendon interposition has developed a higher signal intensity but there was no rupture in this patient, only mild sinovitis around the thumb base. When interpreting MR images of the hand and wrist, it must be kept in mind, that tendons may already show enhanced signal in asymptomatic subjects. However, a fluid rim surrounding a tendon completely, is usually a sign of tenosynovitis. In ambiguous cases, contrast-enhanced T1-weighted imaging may clarify the situation. Images for this section: Page 16 of 27

Fig. 2: Fig 2 Axial T1-weighted image through the wrist in a patient who had undergone a ligamentous reconstruction and tendon interposition arthroplasty with complete trapeziectomy shows what appears to be a regenerated flexor carpi radialis tendon (in white oval). The tendon had decreased signal on the T1-weighted images and is normal in size Page 17 of 27

Fig. 3: Fig 3 Coronal T1-weighted image of the same patient shows a normal appearing of flexor carpi radialis tendon (white arrow) with low signal intensity and an unremarkable caliber and the usual low signal intensity appearance in the surgical tendon insertion with no abnormality. The distance between the base of the thumb and the distal border of radio is 3cm. Fig. 4: Fig 4 DP w/fat SAT image through the wrist of the same patient shows the usual low signal intensity appearance of flexor carpi radialis tendon (in white oval). Page 18 of 27

Fig. 5: Fig 5 Coronal DP w/fat SAT image of the same patient shows a normal appearing of flexor carpi radialis tendon ( arrow) with low signal intensity and an unremarkable caliber and the usual low signal intensity appearance in the surgical tendon insertion with no abnormality (in white oval). Page 19 of 27

Fig. 6: Fig:6 Axial T1WI of the base of the first metacarpal shows the surgical tunnel created To receive the tendon interposition. The tunnel usually has a low/intermediate signal Intensity on all sequences. Fig. 7: Fig:7 DP WI, coronal plane: the normal low signal intensity tendon interposition loop in thesurgical tunnel created at the base of the first metacarpal. There should be no tendon high signal intensity zones, free fluid or cystic lesions associated. Page 20 of 27

Fig. 8: Fig. 8: Coronal DPWI: normal tendon interposition in ints long axis wit the expected low signal intensity inserting on the surgical tunnel at the metacarpal base. Page 21 of 27

Fig. 13: Fig. 13 Axial ultrasound image of the tendon transfer showing a longitudinal split in the tendon with two "hemi" tendons. Fig. 14: Fig. 14 Axial ultrasound image of the tendon transfer showing fluid surrounding the tendon. Although there was no rupture this patient had pain around the metacarpal base and the trapizectomy site. Page 24 of 27

Fig. 16: Fig. 16 Oblique axial DP: the tendon interposition has developed a higher signal intensity but there was no rupture in this patient, only mild sinovitis around the thumb base. Page 26 of 27

Conclusion Trapizectomy and tendon interposition is an effective treatment for rhizarthrosis. The lack of prosthetic material and the predominant soft tissue nature of the post operative changes make MRI and ultrasound ideal imaging techniques for the follow up of these patients. Personal Information References 1. 2. 3. 4. 5. Armstrong AL, Hunter JB, Davis TR. The prevalence of degenerative arthritis of the base of the thumb in post-menopausal women. J Hand Surg Br 1994;19(3):340-1 DouglasP. Beall; Eric R. Ritchie; et all. Magnetic resonance imaging appearance of the flexor carpi radialis tendon after harvest in ligamentous reconstruction tendon interposition arthroplasty. Skeletal Radiol (2006) 35; 144-148 Kristofer S.Matullo, Asif Ilyas, joseph J. Thoder. Arthroplasty of the thumb: A Review; Hand (2007) 2:232-239 Luc De Smet, Wouter Sioen. Basal joint osteoarthritis of the thumb: trapeziectomy, with or without tendon interposition, or total joint arthroplasty. A prospective study Nicola Maffulli, Andrew Irwin, R. Buchan Chesney. Modified Burton and Pellegrini Procedure for trapezium excision, ligament reconstruction and interposition arthroplasty of the tendon of flexor carpi radialis. Operative Orthopadie unt traumatologie (1997) 69-79 Page 27 of 27