Anaesthetics, steroids and platelet-rich plasma (PRP) in ultrasound-guided musculoskeletal procedures

Ultrasound Applications in Pediatric Orthopedics

Imaging techniques have significantly impacted physicians' capability for diagnosis and differential diagnosis for decades. The aim of this review is to update our knowledge regarding the use of US in orthopedic pediatric patients for diagnostic purposes or procedural/therapeutic purposes. This review demonstrates the application of US in trauma (long bone fractures, radial neck fractures, etc.), developmental anomalies such as developmental dysplasia of the hip and congenital dislocation of the patella, soft tissue pathologies (ganglion cyst, popliteal cyst, hemangioma, lipoma, etc.), tumors, apophysitis, joint effusion, and femoral acetabular impingement. US aid in musculoskeletal procedures has also been reported; US-guided procedures such as aspiration, injection, biopsy, foreign body removal, and peripheral nerve block reduce complications, thus making the procedures safer for the patient. Sonography is a fast, low-cost, mobile, non-invasive, and radiation-free diagnostic tool. Even though US requires a skilled operator and has a long learning curve, in experienced hands is the "orthopedic surgeon's stethoscope".

Platelet-rich plasma in the pathologic processes of tendinopathy: a review of basic science studies

Tendinopathy is a medical condition that includes a spectrum of inflammatory and degenerative tendon changes caused by traumatic or overuse injuries. The pathological mechanism of tendinopathy has not been well defined, and no ideal treatment is currently available. Platelet-rich plasma (PRP) is an autologous whole blood derivative containing a variety of cytokines and other protein components. Various basic studies have found that PRP has the therapeutic potential to promote cell proliferation and differentiation, regulate angiogenesis, increase extracellular matrix synthesis, and modulate inflammation in degenerative tendons. Therefore, PRP has been widely used as a promising therapeutic agent for tendinopathy. However, controversies exist over the optimal treatment regimen and efficacy of PRP for tendinopathy. This review focuses on the specific molecular and cellular mechanisms by which PRP manipulates tendon healing to better understand how PRP affects tendinopathy and explore the reason for the differences in clinical trial outcomes. This article has also pointed out the future direction of basic research and clinical application of PRP in the treatment of tendinopathy, which will play a guiding role in the design of PRP treatment protocols for tendinopathy.

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Ultrasound-guided injection of platelet-rich plasma for tendinopathies: a systematic review and meta-analysis

BACKGROUND

In this systematic review and meta-analysis, we evaluated ultrasound (US)-guided injections of platelet-rich plasma (PRP) as conservative treatment of tendinopathies.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE, SCOPUS, OVID, and the Cochrane Library to identify randomized controlled trials (RCT) on the use of US-guided PRP for tendinopathies.

RESULTS

We found 33 RCT (2,025 subjects) that met our inclusion criteria: 8 in lateral epicondylitis, 5 in plantar fasciitis, 5 in Achilles tendinopathy, 7 in rotator cuff tendinopathy, 3 in patellar tendinopathy and 5 in carpal tunnel syndrome. PRP, given as a single injection (20 trials) or multiple injections (13 trials), was compared to US-guided injection of steroids, saline, autologous whole blood, local anesthetic, dry needling, prolotherapy, bone marrow mesenchymal stem cells, or with non-injective interventions. The outcomes more commonly reported included pain and functional measures, subgrouped as in the short-term (<3 months from the intervention), medium-term (3 to 6 months) or long-term (≥12 months). No clear between-group differences in these outcomes were observed in patients with lateral epicondylitis, plantar fasciitis, or Achilles, rotator cuff or patellar tendinopathy. In patients with carpal tunnel syndrome, visual analog scale scores for pain at 3 and 6 months and Boston Carpal Tunnel Questionnaire severity scores at 1, 3 and 6 months were significantly lower in PRP recipients than in controls. The certainty of evidence of all these comparisons was graded as low or very low due to risk of bias, imprecision and/or inconsistency. Pain at the injection site was more common among PRP recipients than among controls receiving other US-guided injections.

DISCUSSION

In patients with tendinopathies, a trend towards pain reduction and functional improvement from baseline was observed after US-guided PRP injection, but in the majority of the comparisons, the effect size was comparable to that observed in control groups.

Extracorporeal Shock Wave Therapy Combined with Platelet-Rich Plasma during Preventive and Therapeutic Stages of Intrauterine Adhesion in a Rat Model

Intrauterine adhesion (IUA) is caused by artificial endometrial damage during intrauterine cavity surgery. The typical phenotype involves loss of spontaneous endometrium recovery and angiogenesis. Undesirable symptoms include abnormal menstruation and infertility; therefore, prevention and early treatment of IUA remain crucial issues. Extracorporeal shockwave therapy (ESWT) major proposed therapeutic mechanisms include neovascularization, tissue regeneration, and fibrosis. We examined the effects of ESWT and/or platelet-rich plasma (PRP) during preventive and therapeutic stages of IUA by inducing intrauterine mechanical injury in rats. PRP alone, or combined with ESWT, were detected an increased number of endometrial glands, elevated vascular endothelial growth factor protein expression (hematoxylin-eosin staining and immunohistochemistry), and reduced fibrosis rate (Masson trichrome staining). mRNA expression levels of nuclear factor-kappa B, tumor necrosis factor-α, transforming growth factor-β, interleukin (IL)-6, collagen type I alpha 1, and fibronectin were reduced during two stages. However, PRP alone, or ESWT combined with PRP transplantation, not only increased the mRNA levels of vascular endothelial growth factor (VEGF) and progesterone receptor (PR) during the preventive stage but also increased PR, insulin-like growth factor 1 (IGF-1), and IL-4 during the therapeutic stage. These findings revealed that these two treatments inhibited endometrial fibrosis and inflammatory markers, thereby inhibiting the occurrence and development of intrauterine adhesions.

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Intra-individual Right-Left Comparative Study of Combined Therapy of Intramatricial Triamcinolone and Platelet-Rich Plasma vs. Intramatricial Triamcinolone Only in Lichen Planus-Associated Nail Dystrophy

Background

While intramatricial triamcinolone is the most commonly used treatment option for onychodystrophy due to lichen planus, the role of platelet-rich plasma (PRP) in the treatment of onychodystrophy is not established. So we combined the two treatment modalities to assess the synergistic action on nail dystrophy.

Aims and Objectives

The aim of this article is to compare the effect of combination of intramatricial triamcinolone and PRP vs. intramatricial triamcinolone alone in the treatment of onychodystrophy.

Materials and Methods

This study was done in 26 and 25 pairs of symmetrical dystrophic nails in hands and feet, respectively. The patients received intramatricial injection of triamcinolone and PRP on one side of finger and toe nails and triamcinolone on the contralateral side.

Results

Statistically significant improvements in grades of dystrophy according to the Nail Dystrophy Grading System (NDGS) in the finger and toe nails treated with combined therapy were obtained (P < 0.001 and = 0.002, respectively). According to the physician global assessment, response to combination therapy was statistically significant between the two comparison groups of finger and toe nails (P = 0.001 and = 0.004, respectively). Similarly, according to the patient satisfaction score, statistically significant difference was found between the comparison groups of combination therapy and single therapy (P < 0.001).

Conclusion

Addition of PRP significantly improved the nail quality. Intramatricial PRP is a safe and effective therapeutic modality in refractory nail dystrophies.

Effect of local anesthetics on platelet physiology and function

Local anesthetics are often used at the site of injury or mixed with platelet-rich plasma to reduce pain when treating orthopedic and sports-related injuries. Local anesthetics have been shown to have deleterious effects on stromal cells, but their impact on platelets has not been investigated. In this study, we aimed to assess the effects of lidocaine, bupivacaine, and ropivacaine on platelet health. Based on the deleterious effects of local anesthetics on nucleated cells, we hypothesized that these compounds would affect platelet viability, intracellular physiology, and function. Platelet preparations were derived from randomly selected donors and exposed to lidocaine 1%, bupivacaine 0.75%, ropivacaine 0.5%, and saline at 1:1 and 1:3 ratios. Platelet morphology, viability, intracellular calcium, production of radical oxygen species (ROS), apoptosis, and adhesion were assessed via fluorescent microscopy and flow cytometry. Bupivacaine resulted in increased ROS production, calcium dysregulation, apoptosis, and reduced platelet adhesion. By contrast, ropivacaine and lidocaine were similar to saline in most assays, except for a low degree of mitochondrial stress as evidenced by increased ROS production. Ultimately, bupivacaine 0.75% was harmful to platelets as evidenced by reduced platelet viability, adhesion, and increased apoptosis, whereas lidocaine 1% and ropivacaine 0.5% were relatively safe at the 1:1 and 1:3 dilutions. Clinical significance: Lidocaine 1% and ropivacaine 0.5% can be used at up to a 1:1 ratio with platelet preparations to reduce the pain and discomfort of PRP procedures while maintaining platelet therapeutic potential.

T2-mapping MRI evaluation of patellofemoral cartilage in patients submitted to intra-articular platelet-rich plasma (PRP) injections

This study evaluated the ability of T2 mapping magnetic resonance imaging at 3 T, in addition to morphological sequences, to assess efficacy of platelet-rich plasma (PRP) injections, characterizing qualitatively and quantitatively the grade of knee cartilage repair in patients with patellofemoral chondropathy. We retrospectively studied 34 patients (22 men, 12 women, mean age 41.8 years, including 22 men) with patellofemoral knee chondropathy, who underwent intra-articular PRP injections and completed a clinical and instrumental follow-up. As control group, we evaluated 34 patients who underwent non-operative therapy. All patients were submitted to clinical (using VAS and WOMAC index) and imaging studies with 3 T magnetic resonance with cartilage analysis with T2 mapping sequences for cartilage analysis before and after treatment. In the study group, mean pre-treatment T2 relaxation time values were 44.2 ± 2.5 ms, considering all articular cartilage compartments, with significant reduction at the follow-up (p < 0.001). At the index compartment, mean pre-treatment T2 relaxation times values were 47.8 ± 3.6 ms, with statistically significant reduction at the follow-up (p < 0.001). Evaluation of focal cartilage lesions reported pre-treatment mean T2 value of 70.1 ± 13.0 ms and post-treatment mean value of 59.9 ± 4.6 ms (p < 0.001). From a clinical point of view, the pre-treatment WOMAC and VAS scores were 18.3 ± 4.5 and 7 (IQR:6-7.2), respectively; the post-treatment values were 7.3 ± 3.2 and 2 (IQR: 1.7-3.0), respectively (p < 0.001). In the control group, despite clinical improvement, we didn't find significant T2 values change during the follow-up period. In conclusion, T2 mapping is a valuable indicator for chondropathy and treatment-related changes over time.

(4-Aminopyridine)-PLGA-PEG as a Novel Thermosensitive and Locally Injectable Treatment for Acute Peripheral Nerve Injury

Traumatic peripheral nerve injury (TPNI) represents a major medical problem that results in loss of motor and sensory function, and in severe cases, limb paralysis and amputation. To date, there are no effective treatments beyond surgery in selective cases. In repurposing studies, we found that daily systemic administration of the FDA-approved drug 4-aminopyridine (4-AP) enhanced functional recovery after acute peripheral nerve injury. This study was aimed at constructing a novel local delivery system of 4-AP using thermogelling polymers. We optimized a thermosensitive (4-AP)-poly(lactide-co-glycolide)-b-poly(ethylene glycol)-b-poly(lactide-co-glycolide) (PLGA-PEG-PLGA) block copolymer formulation. (4-AP)-PLGA-PEG exhibited controlled release of 4-AP both in vitro and in vivo for approximately 3 weeks, with clinically relevant safe serum levels in animals. Rheological investigation showed that (4-AP)-PLGA-PEG underwent a solution to gel transition at 32 °C, a physiologically relevant temperature, allowing us to administer it to an injured limb while subsequently forming an in situ gel. A single local administration of (4-AP)-PLGA-PEG remarkably enhanced motor and sensory functional recovery on post-sciatic nerve crush injury days 1, 3, 7, 14, and 21. Moreover, immunohistochemical studies of injured nerves treated with (4-AP)-PLGA-PEG demonstrated an increased expression of neurofilament heavy chain (NF-H) and myelin protein zero (MPZ) proteins, two major markers of nerve regeneration. These findings demonstrate that (4-AP)-PLGA-PEG may be a promising long-acting local therapeutic agent in TPNI, for which no pharmacologic treatment exists.

Narrative review of multiparametric ultrasound in parotid gland evaluation

Disorders affecting parotid gland represent a heterogeneous group comprising congenital, inflammatory and neoplastic diseases which show a focal or diffuse pattern of appearance. The differentiation of neoplastic from non-neoplastic conditions of parotid glands is pivotal for the diagnostic imaging. Frequently there is evidence of overlapping between the clinical and the imaging appearance of the various pathologies. The parotid gland is also often object of study with the combination of different techniques [ultrasound-computed tomography-magnetic resonance imaging (US-CT-MRI), ex.]. Compared to other dominant methods of medical imaging, US has several advantages providing images in real-time at lower cost, and without harmful use of ionizing radiation and of contrast enhancement. B-mode US, and the microvascular pattern color Doppler are usually used as first step evaluation of parotid lesions. Elastography and contrast-enhanced US (CEUS) has opened further possible perspectives to improve the differentiation between benign and malignant parotid lesions. The characterization of the parotid tumors plays a crucial role for their treatment planning and for the prediction of possible surgical complications. We present, here an updated review of the most recurrent pathologies of parotid gland focusing on the diagnostic power of multiparametric US including CEUS and ultrasound elastography (USE); limitations, advantages and the main key-points will be presented.

Platelet-rich plasma versus corticosteroid injection for treatment of trigger finger: study protocol for a prospective randomized triple-blind placebo-controlled trial

Background

Trigger finger is a common hand disorder that limits finger range of motion and causes pain and snapping of the affected finger. Trigger finger is caused by an imbalance of the tendon sheath and the flexor tendon. The initial treatment is generally a local corticosteroid injection around the first annular (A1) pulley. However, it is not unusual that surgical release of the A1 pulley is required. Moreover, adverse events after local corticosteroid injection or operative treatment may occur. Platelet-rich plasma (PRP) has been shown to be safe and to reduce symptoms in different tendon pathologies, such as DeQuervain’s disease. However, the effects of PRP on trigger finger have not been studied. The aim of this single-center triple-blind randomized controlled trial is to study whether PRP is non-inferior to corticosteroid injection in treating trigger finger. The secondary outcome is to assess the safety and efficacy of PRP in comparison to placebo.

Methods

The trial is designed as a randomized, controlled, patient-, investigator-, and outcome assessor-blinded, single-center, three-armed 1:1:1 non-inferiority trial. The patients with clinical symptoms of trigger finger will be randomly assigned to treatment with PRP, corticosteroid, or normal saline injection. The primary outcome is Patient-Rated Wrist Evaluation and symptom resolution. Secondary outcomes include Quick-Disabilities of the Arm, Shoulder and Hand; pain; grip strength; finger active range of motion; and complications. Appropriate statistical methods will be applied.

Discussion

We present a novel RCT study design on the use of PRP for the treatment of trigger finger compared to corticosteroid and normal saline injection. The results of the trial will indicate if PRP is appropriate for the treatment of trigger finger.

Trial registration

ClinicalTrials.gov NCT04167098. Registered on November 18, 2019.

Advanced diagnostic imaging and intervention in tendon diseases

Degenerative tendon pathology represents one of the most frequent and disabling musculoskeletal disorders. Diagnostic radiology plays a fundamental role in the clinical evaluation of tendon pathologies. Moreover, several minimally invasive treatments can be performed under imaging guidance to treat tendon disorders, maximizing the efficacy and reducing procedural complications. In this review article we describe the most relevant diagnostic features of conventional and advanced US and MRI imaging in tendon disorders, along with the main options for image-guided intervention. (www.actabiomedica.it)

Diagnostic and interventional radiology fundamentals of synovial pathology

The synovial membrane is a specialized mesenchymal tissue that lines the diarthrodial joints surfaces, bursae, and tendon sheaths of the body. This article aims to provide an overview of the fundamentals of synovial tissue, with particular regard to the imaging findings of the main pathologic processes that can affect the synovia and the role of image-guided interventions. (www.actabiomedica.it)

MR Imaging of the Upper Limb: Pitfalls, Tricks, and Tips

MR imaging is the modality of choice to evaluate musculoskeletal pathologies of the upper limb in most settings. However, due to the complexity in anatomy, MR imaging can give a false pathologic appearance and lead to several errors in the interpretation of MR imaging findings. Also, several artifacts can be confused with pathologic entities. This article reviews the most frequently encountered conditions in shoulder, elbow, and wrist MR imaging that can represent diagnostic pitfalls mimicking true pathology, together with some possible tips and tricks that can be useful to solve these equivocal cases and achieve a correct diagnosis.

Ultrasound-guided percutaneous irrigation of calcific tendinopathy: technical developments

Rotator cuff calcific tendinopathy (RCCT) is a common and painful shoulder disease characterised by deposition of calcium into the rotator cuff’s tendond. Different therapeutic options have been proposed, but the ultrasound-guided percutaneous irrigation (US-PICT) is been proved as an effective and safe first-line treatment. It can be performed with a single- of a double-needle tecnique, using warm saline solution to improve the dissolution of the calcific deposit. The procedure is ended with an intrabursal injection of local anaesthetics and slow-release steroids to improve the pain relief and to prevent complications. US-PICT leads to significative improvement in the shoulder funtion and pain relief in the short and long term, with a low complications rate. (www.actabiomedica.it)

Magnetic resonance enterography (MRE) and ultrasonography (US) in the study of the small bowel in Crohn's disease: state of the art and review of the literature

Crohn’s disease (CD) is a chronic idiopathic disease and its diagnosis is based on a combination of clinical symptoms, laboratory tests and imaging data. There isn’t a diagnostic gold standard: the ileocolonoscopy with mucosal biopsies represents the standard for luminal disease, while cross-sectional imaging such as Ultrasound (US), Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) can show transmural alterations and extraintestinal manifestations. CD is usually diagnosed in the young age and after baseline diagnosis, the patients have to undergo to variable follow-up depending on remission or active disease. The aim of our review is to compare Magnetic Resonance Enterography (MRE) to Ultrasonography (US) in the follow-up of CD. (www.actabiomedica.it)

Percutaneous needle biopsy of retroperitoneal lesions: technical developments

Percutaneous Needle Biopsy (PNB) is the insertion of a needle into a suspected lesion or an organ with the aim to obtain cells or tissue for diagnosis. It’s a relatively non-invasive procedure and is performed by radiologist under guidance of imaging techniques such as ultrasound (US), computed tomography (CT), fluoroscopy, magnetic resonance imaging (MRI), and positron emission tomography CT (PET-CT). The choice of imaging technique depends on the evaluation of the target lesion and patient compliance. PNB includes two categories: fine-needle aspiration biopsy (FNAB) that is the use of a thin needle (18-25 gauge) to extract cells for cytological evaluation; and core needle biopsy (CNB) that is the use of a larger needle (9-20 gauge) to extract a piece of tissue for histological evaluation. The indications for biopsy are the characterization of nature (benign or malignant) of a lesion, diagnosis and staging of tumor, and biological or immunohistochemical/genetic analisys on tissue. Success of PNB is the procurement of sufficient material to characterize lesions and to guide the patient outcome. Major complications are rare. PNB became a useful technique in diagnosis and study of retroperitoneal lesions, because of a more suitable access to specific intra-abdominal structures, lowering the risk of injury of interposed structures (such as bowel, great vessels). (www.actabiomedica.it)

Application of diffusion tensor imaging (DTI) and MR-tractography in the evaluation of peripheral nerve tumours: state of the art and review of the literature

Peripheral nerves can be affected by a variety of benign and malignant tumour and tumour-like lesions. Besides clinical evaluation and electrophysiologic studies, MRI is the imaging modality of choice for the assessment of these soft tissue tumours. Conventional MR sequences, however, can fail to assess the histologic features of the lesions. Moreover, the precise topographical relationship between the peripheral nerve and the tumor must be delineated preoperatively for complete tumour resection minimizing nerve damage. Using Diffusion tensor imaging (DTI) and tractography, it is possible to obtain functional information on tumour and nerve structures, allowing the assess anatomy, function and biological features. In this article, we review the technical aspects and clinical application of DTI for the evaluation of peripheral nerve tumours. (www.actabiomedica.it)

Imaging of long head biceps tendon. A multimodality pictorial essay

The aim of this is article is to provide an  imaging review of normal anatomy, most common anatomical variants and pathologies of the long head of the biceps tendon (LHB) encountered during the daily practice.

Neuroimaging in emergency: a review of possible role of pineal gland disease

The pineal gland can be involved in a variety of neoplastic and congenital masses and tumors. Pineal gland neoplasms occur more frequently in children, accounting for 3-8% of intracranial tumors in the pediatric population. Pineal cysts are small lesions usually asymptomatic and encountered incidentally. Pathologic processes involving the pineal region produce signs and symptoms related to the mass effect on the adjacent structures and invasion of surrounding structures. These include several acute symptoms, such as increased intracranial pressure syndrome from obstruction of the aqueduct and consequent hydrocephalus, and Parinaud syndrome. Pineal apoplexy is rare and refers to the sudden neurological deterioration following hemorrhage in the pineal gland, most commonly into a pineal cyst. Knowledge of the clinical presentation and imaging features of these lesions is essential to narrow the differential diagnosis, especially when presenting with acute onset.

Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee

Medial knee pain is common in clinical practice and can be caused by various conditions. In rare cases, it can even be by calcific bursitis of the medial collateral ligament (MCL). Treatment of calcific bursitis and/or calcification of the MCL classically includes observation, local injections, shockwave therapy and surgical resection. We report a case of nontraumatic medial knee pain poorly responsive to conservative treatments. Ultrasound (US) imaging revealed a massive lobed hyperechoic formation with partial acoustic shadow in the MCL context compatible with calcific bursitis, and magnetic resonance imaging (MRI) confirmed the presence of the bursa's calcific deposit surrounded by hyperintense signal compatible with pericalcific edema. We performed a double-needle ultrasound-guided percutaneous lavage (UGPL), which is today a fairly common treatment for many musculoskeletal disorders, such as rotator cuff calcific tendinopathy and elbow extensor tendons pathology, but regarding the knee, it is not part of ordinary care. This report shows the clinical and imaging presentation of calcific bursitis of the MCL and describes in detail the technique to perform the UGPL with a system of two needles, two syringes and a double connection to ensure a correct lavage of the calcium deposit without significant intrabursal pressure increase and consequently without pain during the procedure.

New advances in MRI diagnosis of degenerative osteoarthropathy of the peripheral joints

Degenerative osteoarthropathy is one of the leading causes of the pain and disability from musculoskeletal disease in the adult population. Magnetic resonance imaging (MRI) allows optimal visualization of all tissues involved in degenerative osteoarthritis disease process, mainly the articular cartilage. In addition to qualitative and semiquantitative morphologic assessment, several MRI-based advanced techniques have been developed to allow characterization and quantification of the biochemical cartilage composition. These include quantitative analysis and several compositional techniques (T1 and T2 relaxometry measurements and mapping, sodium imaging, delayed gadolinium-enhanced MRI of cartilage dGEMRIC, glycosaminoglycan-specific chemical exchange saturation transfer gagCEST, diffusion-weighted imaging DWI and diffusion tensor imaging DTI). These compositional MRI techniques may have the potential to serve as quantitative, reproducible, noninvasive and objective endpoints for OA assessment, particularly in diagnosis of early and pre-radiographic stages of the disease and in monitoring disease progression and treatment effects over time.

Migration of calcium deposit over the biceps brachii muscle, a rare complication of calcific tendinopathy: Ultrasound image and treatment

Calcific tendinopathy is characterized by the deposition of calcium, mostly hydroxyapatite crystals, in tendons. Women are more frequently affected than men, with prevalence in the fourth and fifth decades of life. This condition has been reported between 2.5 and 7.5% of healthy shoulders in adults, but other tendons may also be affected. A complication of this condition is the migration of calcium deposits from tendons, usually the supraspinatus, into the subacromial-subdeltoid bursa. We reported a rare complication of calcific tendinopathy, that is, calcium deposits migrated from the long head of the biceps tendon over the proximal tract of the biceps brachii muscle.

Present role and future perspectives of interventional radiology in the treatment of painful bone lesions

Interventional radiology has experienced an exponential growth in the last years. Nowadays it is possible to treat painful benign lesions or metastases with optimal results in terms of pain management and disease control. Among the benign lesions, osteoid osteoma is the most frequently treated with minimal invasive techniques and the results are excellent. Another lesion, traditionally treated with surgery (osteoblastoma) represent today another field of application. In the oncological field, metastases are, numerically, the most diffuse indications for treatment. Research carried out during the last decades has provided the interventional radiologist with a great variety of techniques of ablation and devices for monitoring the sensitive structures close to the target lesion. New ablation techniques and monitoring devices contribute to the achievement of significantly increasing rates of effectiveness and safety of interventional radiology procedures.

Interventional radiology of the thyroid gland: critical review and state of the art

Thyroid nodules are a common incidental finding during a routinely ultrasound (US) exam unrelated to the thyroid gland in the healthy adult population with a prevalence of 20-76%. As treated before with surgery, in the last years new minimally invasive techniques have been developed as an alternative to surgery. The aim of this review, based on newly revised guidelines, is to provide some information regarding the basic principles, indications, materials, techniques, and results of mini-invasive procedures or treatments for thyroid nodules. We performed a narrative review including both newest and representative papers and guidelines based on the different procedures of ablation techniques developed in the last years for the diagnosis and the treatment of thyroid nodules. All examined papers referred very good results in term of volume nodule reduction, improvement in related symptoms and cosmetic problems, with a very low rate of complications and side effects for all the minimally invasive technique analyzed. Obviously, some differents between technique based on different kind of thyroid nodules and different indication were found. In conclusion, many thyroid nodules nowadays could be treated thanks to the advent of new mini-invasive technique that are less expensive and present a lower risk of major complications and side effects compared to surgery.

Platelet-rich plasma injections: an emerging therapy for chronic discogenic low back pain

Autologous platelet-rich plasma (PRP) injections have been investigated in recent years as an emerging therapy for various musculoskeletal conditions, including lumbar degenerative disc disease. Although PRP has received increasing attention from medical science experts, comprehensive clinical reports of its efficacy are limited to those treating knee osteoarthritis and epicondylitis. Use of PRP is gaining popularity in the area of degenerative disc disease, but there is a clear need for reliable clinical evidence of its applications and effectiveness. In this article, we review the current literature on PRP therapy and its potential use in the treatment of chronic discogenic low back pain, with a focus on evidence from clinical trials.

Calcaneal fractures: radiological and CT evaluation and classification systems

Background and aim of the work: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. The articular involvement has been associated with a poor functional outcome. The aim of this work is to describe the radiologic evaluation, the classification systems, the morphological preoperative diagnostic imaging features of calcaneal fractures, highlighting the correlation with the choice of treatment and predictive capacity for the fracture surgical outcome. Methods: A PubMed search was performed for the terms Imaging calcaneus fracture, selecting articles in English language, published in the last two years, where preoperatively diagnostic imaging of fractures of the calcaneus are described. Case reports have not been included. Results: We have collected a number of data that provide important help in preoperative evaluation of calcaneal fractures, such as the new classification system created by Harnroongroj et al, the association of calcaneal fractures with fractures of other bone structures or soft tissue impairment, the use of calcaneotalar ratio in assessing the length of heel. Conclusions: These data suggest an approach geared to the specific choice of treatment and to improving patient outcomes. (www.actabiomedica.it)

Magnetic Resonance Imaging in degenerative disease of the lumbar spine: Fat Saturation technique and contrast medium

Purpose: To examine both anterior and posterior elements of the lumbar spine in patients with low back pain using MRI T2-weighted sequences with Fat Saturation (FS) and contrast enhanced T1-weighted sequences with FS.Materials and methods: Two thousand eight hundred and twenty (2820) patients (1628 male, 1192 female, mean age 54) presenting low back pain underwent MRI standard examination (Sagittal T1w TSE and T2w TSE, axial T1 SE) with the addition of sagittal and axial T2w Fat Sat (FS) sequences. Among all the patients, 987 (35%) have been studied adding Contrast Enhanced (CE) T1w FS sequences after administration of contrast medium. Results: Among 987 patients studied with contrast medium, we found: active-inflammatory intervertebral osteochondrosis in 646 (65%) patients; degenerative-inflammatory changes in facet joints (facet joint effusion, synovitis, synovial cysts) in 462 (47%); spondylolysis in 69 (7%); degenerative-inflammatory changes of the flava, interspinous and supraspinous ligaments in 245 (25%); inflammatory changes of posterior perispinal muscles in 84 (8%) patients. Conclusions: In patients with suspected no-disc-related low back pain, the implementation of T2w FS and CE T1w FS sequences to the standard MR protocol could allow a better identification of degenerative-inflammatory changes more likely associated to the pain. (www.actabiomedica.it)

Weight-bearing MRI of the knee: a review of advantages and limits

Standard knee imaging with MRI is usually performed with patient in recumbent position under non-weight-bearing conditions. Recently, magnetic resonance imaging systems to scan the knee joint under weight bearing conditions has been proposed as an approach to improve the clinical utility of musculoskeletal MRI. Imaging under loading can be useful to understand the natural motion behavior of the knee joint and to identify conditions that are challenging to diagnose by using standard position. We reviewed the literature on weight-bearing MR imaging of the knee to describe the current state of use of such MRI technologies, evaluating the advantages and the potential limitations of these technologies.

Diagnostic imaging and intervention of the musculoskeletal system: state of the art

The study of the musculoskeletal system has always been one of the most important application for diagnostic imaging in radiology (1-4).

Acute and overuse elbow trauma: radio-orthopaedics overview

The correct management of acute, subacute and overuse-related elbow pathologies represents a challenging diagnostic and therapeutic problem. While major trauma frequently requires a rapid surgical intervention, subluxation and minor trauma allow taking more time for diagnostics and planning the correct elective treatment after careful clinical and radiological investigation. In these conditions, communication between orthopaedic surgeon and radiologist allow to create a detailed radiology report, tailored to the patient's and surgeon's needs and optimal to plan proper management. Imaging technique as X-Ray, CT, US, MRI, CTA and MRA all belong to the radiologist's portfolio in elbow diagnostics. Detailed knowledge of elbow pathology and its classification and of the possibilities and limits of each imaging technique is of crucial importance to reach the correct diagnosis efficiently. The aim of this review is to present the most frequent elbow pathologies and suggest a suitable diagnostic approach for each of them.

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures.

Dynamic MRI in the evaluation of the spine: state of the art

INTRODUCTION

Degenerative disease of the spine is a generic term encompassing a wide range of different disease processes, which leads to spinal instability; traumatic/neoplastic events can accelerate this aging process. Therefore, the dynamic nature of the spine and its mobility across multiple segments is difficult to depict with any single imaging modality.

METHODS

A review of PubMed databases for articles published about kMRI in patients with cervical and lumbar spinal desease was performed. We focused on the physiopathological changes in the transition from supine to upright position in spine instability.

DISCUSSION

Until a few years ago, X-ray was the only imaging modality for the spine in the upright position. Of the imaging techniques currently available, MRI provides the greatest range of information and the most accurate delineation of soft-tissue and osseous structures. Conventional MRI examinations of the spine usually are performed in supine position, in functional rest, but the lumbar spine instability is often shown only by upright standing. This can result in negative findings, even in the presence of symptoms. Regardless, the final result is distorted. To overcome this limitation, Kinetic MRI (kMRI) can image patients in a weight-bearing position and in flexed and extended positions, thus revealing abnormalities that are missed by traditional MRI studies.

CONCLUSION

Despite some limitations, the upright MRI can be a complementary investigation to the traditional methods when there are negative results in conventional MRI in symptomatic patients or when surgical therapy is scheduled.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study

BACKGROUND AND AIM

The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal.

METHODS

Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment.

RESULTS

In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly.

CONCLUSIONS

Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.

Scapular fractures: a common diagnostic pitfall

Scapular fractures are one of the most difficult fractures to diagnose on radiographs. Detection can be challenging because of the obscuration by the overlying structures or incomplete imaging due to difficult patient collaboration. Familiarity with imaging characteristics of these abnormalities will allow radiologists to better diagnose and characterize scapular fractures. Three-dimensional computed tomographic scans are considered the gold standard for scapular diagnoses. Treatment strategies differ depending on the type of scapular fractures, but the site and degree of displacement will determine whether surgical intervention should be considered. Complications can occur in fractures that are undiagnosed or improperly evaluated. The purpose of this article is to describe imaging features of traumatic scapular injury, and discuss the role of diagnostic imaging in clinical decision making after shoulder trauma. (www.actabiomedica.it)

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.

Radiofrequency ablation of osteoid osteoma

Osteoid osteoma is a benign bone neoplasm with a reported incidence of 2-3% among all bone primary tumors. Although it is a small and benign lesion, it is often cause of patient complaint and discomfort. It is generally characterized by a long lasting, unremitting pain that typically exacerbates at night, often leading to sleep deprivation and functional limitation of the skeletal segment involved, with a significant reduction of patient daily life activities and consequent worsening of the overall quality of life. Over decades, complete surgical resection has represented the only curative treatment for symptomatic patients. In the last years, new percutaneous ablation techniques, especially radiofrequency ablation, have been reported to be a safe and effective alternative to classical surgery, with a low complication and recurrence rate, and a significant reduction in hospitalization cost and duration. The aim of this article is to provide an overview about the radiofrequency thermal ablation procedure in the treatment of osteoid osteoma. (www.actabiomedica.it)

Talar fractures: radiological and CT evaluation and classification systems

INTRODUCTION

The talus is the second largest bone of the foot. It is fundamental to ensure normal ankle-foot movements as it connects the leg and the foot. Talar fractures are usually due to high energy traumas (road accidents, high level falls). They are not common as they account for 3-5% of ankle and foot fractures and 0.85% of all body fractures. However, talar fractures not correctly diagnosed and treated can lead to avascular necrosis of the astragalus, pseudoarthrosis, early osteoarthrisis and ankle instability, declining the quality of life of patients.

METHODS

A PubMed search was performed using the terms "talus" "talus AND radiology", "talar fractures", and "talar fractures classification", selecting articles published in the last 98 years. We selected articles about pre-treatment and post-surgery talar fractures diagnostic imaging. We also selected articles about talar fractures complications and traumatic talar dislocations. Case reports have not been included.

AIM OF THE WORK

to describe radiological evaluations, classification systems, and biomechanical patterns involved in talar fractures. Also we will briefly describe talar fractures complications and treatment option and strategies.

CONCLUSIONS

This work suggests a radiological approach aimed to classify talar fractures and guide treatment strategies, improving patient outcomes.

Imaging of pediatric foot disorders

Infants and children undergo imaging studies to evaluate a wide variety of congenital and acquired disorders. Imaging protocols have to consider the patient’s comfort, level of anxiety, and smaller size. The first imaging study is usually made with plain radiographs. The routine radiographic examination of the foot includes the anteroposterior (AP), lateral, and oblique projections. Magnetic Resonance Imaging (RMI) provides excellent anatomic detail of cartilage, vasculature and soft tissue thanks to superior soft tissue contrast and spatial resolution, so is valuable in many cases. According to the clinical and objective signs, guided by the radiographs images, we can be oriented to perform Computed Tomography (CT), CT imaging or MRI imaging. CT imaging is useful to observe the bones but it has the disadvantage of using radiation and doesn’t adequately define the bone’s non-ossified portions. On the contrary, MRI imaging is very useful in identifying the cartilaginous parts and vascular and soft tissues, thanks to its superior contrast and spatial resolution. Finally, it is important to orientate the diagnostic process keeping in mind the clinical sign of the patient and to use the most appropriate diagnostic technique. (www.actabiomedica.it)

Developments in the management of bone metastases with interventional radiology

Interventional radiology has known an exponential growth in the last years. Technological advances of the last decades, have made it possible to use new treatments on a larger scale, with safe and effective results. They could be considered as palliative treatments for painful lesions but also curative procedures, as single treatment or specially in combination with other techniques (surgery, radiation and oncology therapies, etc.).The main diffuse techniques are those of thermal ablation that destroy the target lesion through the heat; however there are also endovascular therapies that destroy the target tissue thanks to devascularization. Finally the is also the possibility to stabilize pathological fractures or impending fractures. In this paper all the most diffuse and effective techniques are reviewed and also a discussion of the main indications is done, with an analisys of the success and complications rates.

Magnetic Resonance Imaging correlates of benign and malignant alterations of the spinal bone marrow

BACKGROUND AND AIM OF THE WORK

Bone marrow (BM) abnormalities in the spine are a common, sometimes unexpected, finding on Magnetic Resonance Imaging (MRI), which is the most sensitive imaging modality to evaluate the marrow, and their interpretation can be difficult for the unexperienced radiologist. In this review, the MRI appearance of normal age-related BM changes, as well as the imaging features of benign and malignant diseases, are presented.

DISCUSSION

A large variety of BM signal alterations has been identified and described, including normal variants, BM reconversion,  degenerative changes, infections, spondyloarthritis and osteonecrosis, trauma, neoplastic lesions (both primary or metastatic), post-radiation and chemotherapy sequelae.

CONCLUSIONS

Knowledge of normal age-related BM appearance, normal variants and patterns of involvement in focal and diffuse bone diseases is essential, together with clinical and laboratory data, to narrow the list of the possible differential diagnoses. The radiologist should be familiar with these signal changes, as they can sometimes be discovered incidentally. In this context, it is equally important not to attribute pathological significance to benign alterations and to promptly detect signs of malignant diseases.

Interventional therapeutic procedures in the musculoskeletal system: an Italian Survey by the Italian College of Musculoskeletal Radiology

PURPOSE

To perform an online survey among all members of the Italian College of Musculoskeletal Radiology to understand how therapeutic musculoskeletal procedures are performed in daily practice in Italy.

METHODS

We administered an online survey to all 2405 members about the use of therapeutic musculoskeletal procedures in their institutions asking 16 different questions. Subgroup analysis was performed between general and orthopaedic hospitals with Mann-Whitney U and χ ² statistics.

RESULTS

A total of 129/2405 answers (5.4% of members) were included in our analysis. A median of 142.5 (25th-75th percentiles: 50-535.5; range 10-5000) therapeutic musculoskeletal procedures per single institution was performed in 2016. Arthropathic pain was the main indication. The most common procedures were joint injection, bursal/tendon injection, and irrigation of calcific tendinopathy. Ultrasound-guided procedures were mainly performed in ultrasonography rooms (77.4%) rather than in dedicated interventional rooms (22.6%). Conversely, fluoroscopic procedures were performed almost with the same frequency in interventional radiology suites (52.4%) and in general radiology rooms (47.6%). In most institutions (72%), autologous blood or components were not used. The median number of therapeutic musculoskeletal procedures performed in orthopaedic hospitals was significantly higher than in general hospitals (P = 0.002), as well as for the use of autologous preparations (P = 0.004).

CONCLUSION

Joint injection, bursal/tendon injection, and irrigation of calcific tendinopathy were the most common therapeutic musculoskeletal procedures, being arthropathic pain the main indication. The percentage of procedures and the use of autologous preparations were significantly higher in orthopaedic hospitals than in general hospitals.

Intra-articular benign bone lesions treated with Magnetic Resonance-guided Focused Ultrasound (MRgFUS): imaging follow-up and clinical results

Purpose of this study was to evaluate the employment of MRI-guided Focused Ultrasound (MRgFUS) for treatment of intra-articular benign bone lesions as alternative to surgery, and to monitor the success of the treatment on CT and MRI images. From March 2011 to August 2013, 14 intra-articular benign bone lesions were treated with MRgFUS. All patients were studied by CT and MR imaging. Pain was measured using the visual analogue scale (VAS) before and after treatment (6 and 12 months). All patients in our series demonstrated regression in painful symptomatology during screening. A significant drop in the mean VAS pain score (from 7.8 to 0.6) was observed at 12-month follow-up, and pain medication was no longer needed after treatment. No complications were observed. Three diagnostic imaging signs were found suggesting absence of biological activity and confirming the clinical findings: calcification of the treated lesion, lack of contrast enhancement and disappearance of bone oedema around the lesions.

CONCLUSION

the employment of MRgFUS is safe and effective in the treatment of intra-articular benign bone lesions. The clinical outcome is satisfactory, and the success of the treatment is confirmed by diagnostic imaging.