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Musculoskeletal Imaging Original Research

Zubler et al. Osseous Causes of Elbow Stiffness Musculoskeletal Imaging Original Research

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Elbow Stiffness: Effectiveness of Conventional Radiography and CT to Explain Osseous Causes


Veronika Zubler 1 Nadja Saupe1 Bernhard Jost 2 Christian W. A. Pfirrmann1 Juerg Hodler 1 Marco Zanetti1
Zubler V, Saupe N, Jost B, Pfirrmann CWA, Hodler J, Zanetti M

OBJECTIVE. The purpose of our study was to evaluate the effectiveness of conventional radiography and CT for explaining the osseous causes of elbow stiffness. MATERIALS AND METHODS. Two independent readers analyzed loose bodies and osteophytes on conventional radiography and CT (or CT arthrography) of the elbow in 94 consecutive patients (71 men, 23 women; mean age, 41 years; range, 1868 years). Arthroscopic or surgical correlation was available in 58 (62%) patients. In all 94 patients, the expected restriction of motion was measured on images and correlated (Pearsons correlation) with the clinical restriction of motion. Kappa statistics were performed for interobserver agreement. RESULTS. Accuracy for detecting loose bodies was 67% with conventional radiography and 79% with CT. Differences in accuracy were most pronounced for detecting loose bodies in the posterior joint space (64% for conventional radiography vs 79% for CT). Accuracy for detecting osteophytes was 69% with conventional radiography and 76% with CT. Expected restriction of motion on conventional radiography correlated significantly with clinical restriction for only one reader for flexion (R = 0.21, p = 0.04). Expected restriction of extension on CT correlated significantly with clinical restriction of motion by both readers (R = 0.34 and 0.33, p = 0.001 and 0.001, respectively). Expected restriction of flexion on CT correlated significantly by one reader (R = 0.24, p = 0.02). Interobserver agreement with regard to detection of both loose bodies and osteophytes was higher for CT ( = 0.83 and 0.76) than for conventional radiography (0.64 and 0.60). CONCLUSION. CT is more effective than conventional radiography in explaining the osseous causes of elbow stiffness. lbow stiffness can be caused by osseous or soft-tissue abnormalities that may be located either within the joint or outside of the joint. Intraarticular causes include posttraumatic arthritis, joint incongruity, ankylosis of articular surfaces, articular adhesions, loose bodies, and osteoarthritis with bone spurs and proliferative synovitis. Extraarticular causes include heterotopic bone formation, capsular thickening, and musculotendinous contracture [1]. Soft-tissue abnormalities (e.g., synovitis, insertion tendinopathies, and collateral ligament lesions) are preferably evaluated by ultrasound or MRI [2]. Soft-tissue abnormalities frequently can be treated conservatively, whereas osseous abnormalities, such as loose bodies, osteophytes, or joint incongruity, are more commonly treated by arthroscopy or open surgery [35]. Osseous abnormalities in elbow stiffness are most commonly clarified by radiography and CT.

Keywords: conventional radiography, CT, elbow stiffness, restriction of motion DOI:10.2214/AJR.09.3741 Received September 30, 2009; accepted after revision December 14, 2009.
1 Department of Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland. Address correspondence to V. Zubler (veronika.zubler@balgrist.ch). 2 Department of Orthopedic Surgery, Orthopedic University Hospital Balgrist, Zurich, Switzerland.

WEB This is a Web exclusive article. AJR 2010; 194:W515W520 0361803X/10/1946W515 American Roentgen Ray Society

Conventional radiography is still the primary step in the evaluation of elbow stiffness [6]. CT or CT arthrography is generally considered by radiologists to be more accurate for evaluation of loose bodies than conventional radiography. However, controversy exists [79]. Canadian orthopedic surgeons concluded in 2005 that neither CT arthrography nor MRI is reliable or more accurate than conventional radiography alone to detect loose bodies in patients with elbow stiffness [10]. To our knowledge, even less evidence exists as to whether CT is at all more effective than conventional radiography in evaluating the osseous causes of elbow stiffness. The technologic advance of MDCT in the last decade with the possibility of excellent secondary reformations caused the assumption that CT may be superior to conventional radiography in explaining osseous causes of elbow stiffness. Thus, the purpose of this investigation was to evaluate the effectiveness

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Zubler et al. of conventional radiography and CT for explaining the osseous causes of elbow stiffness. Material and Methods Patient Population
Downloaded from www.ajronline.org by 202.67.46.13 on 08/17/13 from IP address 202.67.46.13. Copyright ARRS. For personal use only; all rights reserved Two hundred seven consecutive patients referred for CT or CT arthrography of the elbow between September 2004 and September 2008 were identified in our PACS system. Patients older than 18 years were included in the study when conventional radiography was performed within 100 days before or after CT without any elbow surgery in between. Patients were excluded when image quality was nondiagnostic (motion artifact, absence of secondary reformation, n = 3), in the presence of a tumor (n = 12), after a recent fracture or dislocation (within 6 months before CT) (n = 13), presence of an elbow prosthesis (n = 6), hemophiliac arthropathy (n = 2), posttraumatic pseudoarticulation of the humerus (n = 2), severe posttraumatic deformity of the joint (n = 4), extensive osteosynthesis material (n = 2), ankylosis of the joint (n = 2), and spasm of the triceps muscle caused by a birth defect (brachial plexus damage) (n = 1). The final study group consisted of 94 patients (71 men and 23 women [mean age, 41 years; range, 1868 years]). Thirty-seven patients (37/94, 39%) underwent standard CT, and 57 patients (57/94, 61%) underwent CT arthrography. Fifty-eight of the 94 patients (62%) underwent surgery within 190 days (mean, 43.4 days; range 0190 days) after CT. Twenty-eight of these 58 (48%) underwent open surgery; 27 of 58 (47%), arthroscopy; and three of 58 (5%), implantation of a prosthesis. Surgery and arthroscopy included dbridement, resection of osteophytes, removal of loose bodies, releasing of fibrosis, resection of plicae, neurolysis of the ulnar nerve, and the Outerbridge-Kashiwagi procedure. In each patient, only one elbow was evaluated (34 left elbows, 60 right elbows). The mean interval between conventional radiography of the elbow and CT or CT arthrography was 32 days (range, 098 days). Our institutional review board does not require approval or informed consent for the retrospective review of patient records or images. However, patients rights are protected by a law that requires that they must be informed that their charts and images might be reviewed for scientific purposes and that grants patients the opportunity to forbid such use of their data. All patients agreed to the use of their data. views of the elbow (sitting patient, arm 90 elevated, elbow flexion 90 [if possible], beam orientation from radial to ulnar). Intraarticular contrast medium was injected in a standardized fashion. CT was performed on a Somatom Plus 4 scanner (Siemens Healthcare) (57 of 94, 61%) and on a Brilliance CT 40 scanner (Philips Healthcare) (37 of 94, 39%) The imaging parameters were ultra high resolution; 120 kV; 150 mAs; collimation, 20 0.625; matrix, 150; thickness, 0.67; increment, 0.33; window center, 450; and window width, 2,000. Transversal, coronal, and sagittal reformations were performed (thickness, 2.0; increment, 2.0). Patients were examined in the prone position with the arm extend if possible over the head and the forearm as extended as far as possible. Thirty-seven patients (37/94, 39%) underwent standard CT and 57 patients (57/94, 60%) underwent CT arthrography.

Conventional Radiography, CT, and CT Arthrography


Conventional radiographic assessment included anteroposterior views (sitting patient, arm 90 elevated, elbow extended (if possible), wrist supinated, beam orientation anteroposterior) and lateral

Fig. 126-year-old man with clinically 20 restriction of extension and 25 restriction of flexion. A, Lateral conventional radiograph obtained anteriorly in fossa coronoidea shows apparent small osteophyte (arrow ). Not clearly visible are osteophytes in fossa olecrani and loose body. B, Transverse CT image shows large osteophytes (arrowheads ) in fossa coronoidea and fossa olecrani. C and D, Sagittal CT reformation image (C) shows osteophytes in fossa coronoidea and fossa olecrani and loose body in anterior aspect of joint. Diagram (D) shows angles formed with rays connecting maximal extent of loose bodies (a1) or osteophytes (b1 [anterior], b2 [posterior]) to center of capitulum humeri. By adding these measured angles, degree of compromise was estimated separately for flexion and extension.

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Osseous Causes of Elbow Stiffness


For CT arthrography, 1 mL of local anesthetic (mepivacain hydrochloride 2%, Scandicain, AstraZeneca) and a mean of 6 mL of iodinated contrast agent (iopamidol, 200 mg/mL, Iopamiro 200, Bracco), were injected under fluoroscopic control. The delay between the injection and CT was less than 15 minutes.

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Evaluation of Images
Both conventional radiography and CT or CT arthrography were evaluated independently by two experienced musculoskeletal radiologists with 15 and 4 years of professional experience in musculoskeletal radiology. After separate reading, a consensus was reached. The readers were blinded to the clinical findings. The readers evaluated the presence of osseous abnormalities potentially restricting flexion or extension using the anteroposterior and lateral views from conventional radiography and the transversal, coronal, and sagittal reformations from the CT. These abnormalities were categorized as calcified loose bodies (located anteriorly and/or posteriorly) and osteophytes (anterior, posterior, humeral, ulnar, and/or radial). On images, the expected restriction of motion caused by osseous structures (loose bodies and/or osteophytes) was assessed. A circle was drawn with the center in the capitulum humeri on the conventional lateral radiograph or sagittal CT reformation. Loose bodies and osteophytes within this circle hampering the normal flexion and extension were noted. Angles (a, b, and c) were formed with rays connecting the maximal extent of the loose bodies (a) or osteophytes (b and c) to the center of the capitulum humeri. By adding these measured angles, the degree of compromise was estimated separately for flexion and extension (Figs. 13). We used following formulas: a1 + b1 + c1 = restriction of flexion, a2 + b2 + c2 = restriction of extension with angles measured in degrees. In the formulas, a1 = angle restricted by loose bodies in the anterior aspect of the joint; b1 = angle restricted by humeral osteophytes in the anterior aspect of the joint; c1 = angle restricted by ulnar and/or radial osteophytes in the anterior aspect of the joint; a2 = loose bodies in the posterior aspect of the joint; b2 = humeral osteophytes in the posterior aspect of the joint; and c2 = ulnar radial osteophytes in the posterior aspect of the joint.

Fig. 2 60-year-old man with restriction of extension (15) and restriction of flexion (5). A and B, Similar to Fig. 1, on lateral conventional radiograph, osteophyte in anterior aspect of humerus (arrow, A ) is suspected. It was not seen in anteroposterior view. C and D, CT images correspond better with minimal restriction of motion of 5 produced by small osteophyte in radial aspect of humerus (arrow, D). Fossa coronoidea, however, is completely free (arrowheads, C and D).

clinical restriction of motion was measured by orthopedic residents with a handheld goniometer.

Statistical Analysis
Sensitivity, specificity, and accuracy were calculated for the diagnosis of loose bodies and osteophytes at the various sites. Pearsons correlation was calculated between restriction of motion as expected on images and restriction of motion measured clinically. For assessing interobserver agreement, kappa values were calculated. According to Landis and Koch [11] kappa values of 0.41

0.60 indicate moderate, 0.610.80 substantial, and 0.811.00 almost perfect agreement. All analyses were performed with statistical software (SPSS for Windows, release 16.0.1, SPSS). A p value <0.05 was considered statistically significant.

Standard of Reference
The standard of reference of the diagnostic accuracy for loose bodies and osteophytes was arthroscopy (27/58, 47%) and open surgery (31/58, 53%). The standard of reference for expected restriction of motion determined on images was the clinical restriction of motion in all 94 patients. The

Results Diagnostic Accuracy for Detecting Loose Bodies and Osteophytes Accuracy for detecting loose bodies was 67% with conventional radiography and 79% with CT (Table 1). Sensitivity and specificity

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Zubler et al. ly evaluated. The outlier could be explained by a pseudarthrosis in the proximal humeral shaft that was not visible on conventional radiography and CT images and that produced a restriction of motion due to extreme pain. Expected restriction of motion in the lateral view on conventional radiography correlated significantly with clinical restriction by one reader for flexion (R = 0.21, p = 0.04) but not for the other measurements (extension, reader 1; flexion and extension, reader 2). Expected restriction of extension on CT in the sagittal reformations correlated significantly with clinical restriction of motion by both readers (R = 0.34 and 0.33, p = 0.001 and 0.001). Expected restriction of flexion on CT in the sagittal reformations correlated significantly for one reader (R = 0.24, p = 0.02) (Tables 2 and 3). Interobserver Agreement Conventional radiography Interobserver agreement for detection of loose bodies on conventional radiography was substantial overall (0.64) and in the anterior aspect (0.67) but moderate in the posterior aspect (0.53). Interobserver agreement for detection of osteophytes was moderate or substantial at the various sites: anterior, 0.6; posterior, 0.69; humeral, 0.56; ulnar, 0.73; and radial, 0.58. CT Interobserver agreement for detection of loose bodies on CT was almost perfect: 0.83 (anterior, 0.86; posterior, 0.83). Interobserver agreement for detection of osteophytes was substantial or almost perfect at the various sites (anterior, 0.72; posterior, 0.73; humeral, 0.76; ulnar, 0.67; and radial, 0.8) (Table 4). C D Discussion Our study shows that CT is more effective than conventional radiography for evaluating the osseous causes of elbow stiffness. The higher effectiveness of CT is based on better detection of loose bodies and osteophytes. Loose bodies and osteophytes in the anterior and posterior joint space, especially in the fossa coronoidea and in the fossa olecrani, are often invisible on conventional radiography. Such osteophytes in the fossae may play an important biomechanical role. The humeroulnar joint is a classical hinged joint with one plane of motion in the flexion and extension direction. Therefore, any osseous obstacle restricts motion. For therapy, loose bodies and osteophytes in the fossa olecrani and coronoidea are preferably removed by dbridement, either by

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Fig. 3 66-year-old man with osteoarthritis of elbow; 25 restriction of flexion and 35 restriction of extension were measured clinically. A and B, Conventional radiographs show large anteriorly located loose body (arrow, A ), explaining restriction of motion. The 35 restriction of extension was not completely explained by radiographs. C and D, CT images show osteophytes in fossa olecrani (white arrowheads ), main cause of restriction of extension, and osteophytes in fossa coronoidea (black arrowheads ). Restriction of motion is also explained by osteophytes in ulna (arrows , C). Large loose body on CT is shown in transverse CT image (arrow, D).

were 86% and 48% for conventional radiography and 93% and 66% for CT. Differences in accuracy were most pronounced for detecting loose bodies in the dorsal joint space (accuracy, 64% for conventional radiography vs 79% for CT; sensitivity, 60% vs 90%; and specificity, 66% vs 74%). Accuracy for detecting osteophytes was 69% with conventional radiography (sensitivity 62%, specificity 87%) and 76% with

CT (sensitivity 81%, specificity 63%). Differences in accuracy were most pronounced for humeral osteophytes (accuracy 65% conventional radiography vs 76% for CT, sensitivity 41% vs 84%, and specificity 96% vs 65%). Restriction of Motion Measurements One single outlier was detected on correlation plots and then removed for analysis. Thus, 93 patients instead of 94 were final-

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Osseous Causes of Elbow Stiffness TABLE 1: Diagnostic Accuracy in Percentages of Conventional Radiography and CT for Loose Bodies and Osteophytes
No. of Findings True-Positive Parameter Loose bodies Downloaded from www.ajronline.org by 202.67.46.13 on 08/17/13 from IP address 202.67.46.13. Copyright ARRS. For personal use only; all rights reserved Anterior Posterior Osteophytes Anterior Posterior Humeral Ulnar Radial 25 16 12 26 18 18 13 22 7 27 17 18 34 28 29 27 30 14 True-Negative 14 26 25 14 21 19 25 16 40 19 29 28 10 15 12 17 11 38 False-Positive 15 12 13 2 1 3 1 1 2 10 9 10 6 7 10 9 6 4 False-Negative 4 4 8 16 18 18 19 19 9 2 3 2 8 8 7 5 11 2 Sensitivity (%) 86 80 60 62 50 50 41 54 44 93 85 90 81 78 81 84 73 88 Specificity (%) 48 68 66 87 95 86 96 94 95 66 76 74 63 68 55 65 65 91 Accuracy (%) 67 72 64 69 67 64 65 65 81 79 79 79 76 74 71 76 70 90 Radiography CT Radiography CT Radiography CT Radiography CT Radiography CT Radiography CT Radiography CT

TABLE 2: Correlation Between Restrictions of Motion Measurements With Clinical Restriction


Conventional Radiography Reader 1 2 Extension p = 0.13, R = 0.16 p = 0.43, R = 0.08 Flexion p = 0.28, R = 0.11 p = 0.04, R = 0.21 Extension p = 0.001, R = 0.34 p = 0.001, R = 0.33 CT Flexion p = 0.02, R = 0.24 p = 0.06, R = 0.19

Note R = Pearsons`s correlation factor, Conv. radiographs = conventional radiographs. Bold indicates statistical significance. (p < 0.05).

TABLE 3: Restriction of Motion Measurements


Handheld Goniometer Type of Motion Flexion () Extension () Mean (SD) 18 (20) 21 (15) Conventional Radiography Reader 1 Mean (SD) 16 (17) 17 (17) Reader 2 Mean (SD) 21 (18) 16 (19) Reader 1 Mean (SD) 19 (17) 20 (18) CT Reader 2 Mean (SD) 19 (18) 23 (21)

TABLE 4: Interobserver Agreement Results


Conventional Radiography Parameter Loose bodies Anterior Posterior Osteophytes Anterior Posterior Humeral Ulnar Radial 0.64 0.67 0.53 0.60 0.59 0.69 0.56 0.73 0.58 CT 0.83 0.86 0.83 0.76 0.72 0.73 0.76 0.67 0.80

open surgery or by arthroscopy. Open dbridement of the anterior and posterior compartments of the elbow can be performed either directly through a single posterior [12] or a single lateral approach [13] or through

combined medial and lateral approaches. A classical surgical technique is the Outerbridge-Kashiwagi procedure. When this procedure is performed, loose bodies and osteophytes are removed from the olecranon and

coronoid process through a posterior incision and a hole is trephined through the olecranon fossa in the distal humerus to allow access to the anterior part of the elbow joint [14]. The use of CT in musculoskeletal radiology has increased in recent years because of the availability of high-resolution reformations associated with MDCT. MDCT reformations are widely used in musculoskeletal radiology after acute bone trauma and postoperatively after arthrodesis and spondylodesis [15, 16]. Our study emphasizes that CT is also useful for assessing loose bodies and osteophytes in the elbow. The sagittal reformations seem to be most important, given that quantitative assessment of restriction of flexion and extension can be performed only in the sagittal imaging plane. Moreover, sagittal reformations resemble conventional lateral tomograms. Before CT was available with high-resolution reformations, conventional lateral tomography was a preferred imaging technique by many elbow surgeons for assessing mechanical elbow stiffness [17]. On sagittal reformations, the quantitative restriction of motion caused by the loose bodies or osteophytes can be estimated by the method shown in this article. Our orthopedic surgeons are comfortable when they can correlate the restriction of motion on images with the restriction of motion measured in their patients before surgical intervention. Admittedly, CT allows only a gross radiologic estimation of the restriction of motion. Soft-tissue abnormalities rather than osseous abnormalities may be responsible for restriction of motion as well. Thus, theoretically a patient can suffer from a considerable restriction of motion caused by scars or a hypertrophic synovial plica

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Zubler et al. [18]. On the other hand, although such softtissue abnormalities can be seen with MRI [19, 20], we have not found any data reporting the correlation of such findings (plicae, scars) with elbow stiffness. Our results contradict somewhat the results from a previous study [10] in which CT arthrography and MRI were found not to be more effective than conventional radiography [10]. Dubberley et al. [10] found relatively high sensitivities (88100%) for the detection of loose bodies with MRI and CT arthrography but relatively low specificities of between 20% and 70%. Radiography had a similar sensitivity and specificity of 84% and 71%. One reason our study showed higher effectiveness of CT over conventional radiography may be related to the different CT technique. Dubberley et al. used double-contrast CT arthrography and we used single-contrast CT arthrography. Moreover, Dubberley et al. used a section thickness of 1 mm, whereas we used a section thickness of 0.67 mm, and finally, they did not have our measurement method to assess the expected restriction of motion caused by osseous structures. Our study had a number of limitations. The retrospective study design is associated with an inhomogeneous study population. However, the consecutive study inclusion criteria guaranteed an unselected wide range of abnormalities. The retrospective study design may partially explain why the accuracies were relatively low. We retrospectively used the available arthroscopic reports or surgical reports, but the surgeons themselves were not specifically asked to report findings (e.g., osteophytes) as would have been done in a prospective study. The relatively low specificity and high false-positive results for osteophytes on CT images may be explained by the use of arthroscopy as standard of reference. Tiny osteophytes can be probably missed during arthroscopy. The absence of surgical correlation in 38% patients represents a limitation of the study, but the overall number of patients (58) with surgical correlation is still substantial. A further limitation of our study is that 60% of the patients underwent CT arthrography, whereas 40% underwent CT without intraarticular contrast medium. The question as to whether or not CT arthrography is superior to conventional CT for loose bodies is still controversial [7, 10, 21]. This controversy is reflected by the referrals of patients to our department for imaging for whom CT and CT arthrography were requested for the same clinical problem. In summary, our study shows that CT is more effective than conventional radiography for evaluation of osseous elbow stiffness on the basis of higher accuracy and higher interobserver agreement for detecting loose bodies and osteophytes, especially when they are located in the fossa coronoidea or fossa olecrani. Differences in accuracy between CT and conventional radiography are most pronounced for detecting loose bodies in the posterior joint space. Therefore, the highest gain of diagnostic information with CT can be expected in patients with restricted extension. Finally, our study presents a CT measurement method that allows the prediction of the clinical restriction of motion to a certain degree. References
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