[Surgical treatment of osteochondromas: indication in "Strategic Exostosis"]. / Indicazioni al trattamento chirurgico degli osteocondromi: "Esostosi strategica".

OBJECTIVE: The osteochondromas represents is the most frequent benign lesion interesting the bone tissue. This lesion, often asymptomatic, can arise through mechanical, irritative or painful syndromes: "strategic exostosis". MATERIALS AND METHODS: In our present study we retrospectively evaluated 65 Caucasian patients, which have been treated surgically for symptomatic solitary exostosis from March 2004 to Jan 2011. The most frequent symptom referred by patient has been represented by pain. The others complains were related to nervous compression, esthetic injury and a reduction of range of motion. By using the VAS score we evaluated the post-operative bone pain at 3, 12 and 24 months. At the end of follow up we evaluated by a validated questionnaire the grade of patient satisfaction. RESULTS: No major surgical complication were found. The rate of disease recidivism was null. Only a small group of patient referred a persisting pain in the lesion area during the two years follow up. In this subgroup the rate of satisfaction was obviously reduced. CONCLUSIONS: In our opinion the surgical treatment of strategic exostosis, is safe and it should be recommended, since it allows to eliminate the noise with a low incidence of complications. The large majority of out patients were satisfied of the clinical improvement they experienced.

MR-guided focused ultrasound (MRgFUS) ablation for the treatment of nonspinal osteoid osteoma: a prospective multicenter evaluation.

BACKGROUND: Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel imaging-guided surgical technique that allows the performance of noninvasive and radiation-free ablation. Presently, computed tomography (CT)-guided radiofrequency ablation, a minimally invasive percutaneous technique, is the standard for treating symptomatic osteoid osteomas. The purpose of this study was to evaluate the use of MRgFUS ablation for the treatment of nonspinal osteoid osteomas in terms of technical success, complications, and clinical success through one year of follow-up. METHODS: In this prospective multicenter study, thirty consecutive patients with a nonspinal osteoid osteoma were enrolled between May 2010 and April 2012 at three different university centers; twenty-nine of the patients were treated with use of MRgFUS. Lesions had been previously diagnosed on the basis of imaging, including dynamic contrast-enhanced MR. The mean number of sonications and energy deposition were determined. Technical success was evaluated through an assessment of complications immediately after treatment. Clinical success was determined on the basis of pain reduction as measured with a visual analog scale (VAS), recurrence, and long-term complications through twelve months. RESULTS: Technical success of MRgFUS was observed for all twenty-nine patients. The mean number of sonications (and standard deviation) was 7 ± 3, and the mean delivered acoustic energy was 1180 ± 736 J. At the twelve-month follow-up, complete clinical success was observed in twenty-six (90%) of the twenty-nine patients (95% confidence interval [CI] = 84 to 95; mean VAS, 0 ± 0 points). Partial success was observed in three (10%) of the twenty-nine patients (95% CI = 5 to 16; mean VAS score, 5 ± 0 points); two of these patients subsequently underwent CT-guided radiofrequency ablation, and one underwent open surgery. Pain score values showed a significant reduction (p < 0.001) between baseline (mean VAS score, 8 ± 1 points) and post treatment (mean VAS score, 1 ± 2 points). No complications were observed. CONCLUSIONS: MRgFUS may be an effective and safe alternative approach in the treatment of nonspinal osteoid osteoma. A complete clinical success rate of 90% was demonstrated without adverse events. MRgFUS is totally noninvasive and eliminates radiation exposure.

Cross-sectional imaging in a case of adventitial cystic disease of the popliteal artery.

Adventitial cystic disease of the popliteal artery is an unusual condition of uncertain etiology, in which a mucin-containing cyst forms in the wall of the artery and produces lower extremity claudication, typically in young and middle-aged men. A diagnosis of adventitial cystic disease of the popliteal artery was made preoperatively in a 47-year-old man by means of several imaging modalities, including angiography, magnetic resonance imaging, and ultrasound. The pathological findings confirmed the suggested diagnosis.

Rehabitation of allograft with bone dehydrated with solvents in reconstruction after removal of bone tumors: MRI evaluation.

It was the purpose of this study to analyze the behavior of Tutoplast bone allograf to fill cavities produced by the removal of benigning bone tumors of those with local malignancy. X-ray and MR images obtained during follow-up demonstrated an increase in the signal in all of the sequences within the graft, indicating complete rehabitation of the grafted area.

[New prospects in the assessment of the knee extensor complex with dynamic magnetic resonance]. / Nuove prospettive nella valutazione con Risonanza Magnetica dinamica del complesso estensore del ginocchio.

INTRODUCTION: Altered patellofemoral biomechanics may result in pain, instability and early involutive processes. Magnetic Resonance Imaging (MRI), with its panoramic capabilities, has proved to be an effective technique in the study of knee extensor complex changes. The diagnostic advantages of dynamic studies of patellofemoral kinetics are reported in the recent scientific literature. We investigated the diagnostic potentials of passive studies of the knee extensor complex with sagittal and axial cine MRI. Then, we developed and optimized an innovative study method overcoming the limitations of the other dynamic techniques for the correct assessment of patellofemoral biomechanics. MATERIAL AND METHODS: We studied the knee with a .2 T permanent magnet dedicated to the limbs and acquired the images in different positions of flexion-extension with T1-weighted SE and T2-weighted GE sequences. We examined 21 healthy volunteers and 37 of 38 patients with anterior knee joint pain of suspected patellofemoral origin. All the images needed for dynamic studies were acquired in about 20 minutes. For the scan planes not to be affected by patellar motion in the different degrees of knee extension, it is necessary to acquire single axial images to be edited in cine motion afterwards. Each acquisition is aligned along sagittal reference planes depiciting always the same patellar aspect. RESULTS: Significant correlations were found between clinical and cine MR findings in 25 patients. In particular we depicted some extensor complex impingement conditions missed at conventional MRI, which clarified the role played by patellar dysplastic changes in cartilage microtraumas. Our technique was accurate, quite easy to perform and repeatable. We performed cost-effective dynamic studies which were useful in the evaluation of patients with anterior knee pain in whom conventional MRI had failed to provide enough information. CONCLUSIONS: Our technique differs from other passive or active dynamic studies reported on in the literature because the patellar volume does not change during acquisitions. This permits to decrease morphological changes and to simplify, on cine MR reconstructions, the specific analysis of patellofemoral dynamics during flexion-extension. Fewer morphological changes also mean a more accurate analysis showing the role of patellar dysplasia in cartilage microtraumas. Our dynamic MR protocol is accurate, easy to perform and to repeat; it allows dynamic studies in the patients with poor static MR findings.

Synovial cysts: clinical and neuroradiological aspects.

Lumbar and intraneural synovial cysts are uncommon lesions, although their incidence has increased since the introduction of MRI. The authors describe the results of a study comprising 23 patients with synovial cyst (5 lumbar, 19 intraneural). Neuroradiological investigations included CT scan and MRI; however, it was not always possible to diagnose the nature of the lesion. In 18 cases the lesion was removed totally including its capsule; in the other 5 cases it was removed subtotally. Seven of the 23 patients presented a total remission of symptoms/signs, 11 improved and 5 remained unchanged. The importance of treating synovial cysts as radically as possible is discussed together with their most significant clinical and neuroradiological aspects.

[Role of magnetic resonance in the evaluation of the normal and osteochondrosis hip in early and late childhood]. / Ruolo della Risonanza Magnetica nella valutazione dell'anca normale e osteocondrosica nella prima e seconda infanzia.

INTRODUCTION: Despite MR potentials, few studies investigate the features of normal hips and of hip osteochondrosis in early and late childhood. We report our personal experience with MRI of hip osteochondrosis in pediatric patients. MATERIAL AND METHODS: MR images were obtained with total body MR equipment at medium and high fields. The normal hips were studied in children aged 34 months to 6 years with abdominal-urinary tract disorders and in 9 patients of the same age with unilateral Perthes disease. Hip osteochondrosis was studied in 6 children with Catteral's type III and IV and in 3 with type I and II disease. General anesthesia was never necessary to perform MRI. RESULTS: MRI exactly defined the cephalic anatomic profiles of normal hips which are not depicted with conventional radiography before the femoral head cartilage ossifies completely. MR contrast resolution was very high in depicting the maturation of the epiphyseal nucleus and its exact site in the cartilagineous epiphyseal hemisphere proximal to the femur. The analysis of MR morphological and structural changes permitted to correlate MR findings with the histopathologic features described in the literature. In addition, MRI of childhood hip osteochondrosis showed maked structural changes of the epiphyseal nucleus which are usually missed with conventional radiography. MRI permits early location of the abnormal area and the recognition of growing disk abnormalities; it also shows the whole cephalic cartilage and the changes of the epiphyseal nucleus evolution, which permits to differentiate osteochondrosis evolution from recessive patterns. Finally, MRI clearly showed the increased equatorial diameters of the involved femoral heads and the associated decrease in polar diameters, which is essential to study the biomechanics of hip osteochondrosis and therefore to plan treatment. CONCLUSIONS: MRI, even with coronal sequences and T1-weighting only, permits: 1) to image normal hips and hip osteochondrosis, especially in early and late childhood; 2) to clearly define cephalocotyloid relationships; 3) to depict the actual anatomic margins of the head and its structure; 4) to investigate the head cartilage extent and to locate the ossification nucleus. These morphologic and structural data are very useful to diagnose and manage hip osteochondrosis in the evolutive age. MRI shows abnormal changes in anatomic structures which are not seen with conventional radiography and demonstrates the evolution of the osteochondrosis process over time. In children over six, at the end of the ossification process of the head cartilage, conventional radiography alone is often sufficient to depict cephalocotyloid relationships and the MR diagnostic criteria of bone-cephalic diseases are similar to those used in adult hip studies.

Accelerated rehabilitation after arthroscopic meniscal repair: a clinical and magnetic resonance imaging evaluation.

Twenty-two patients who underwent meniscal repair using the outside-in technique combined with anterior cruciate ligament (ACL) reconstruction were submitted to an accelerated rehabilitation protocol that included immediate full range of motion and weightbearing. The patients were reviewed postoperatively by means of clinical assessment and magnetic resonance imaging (MRI) after an average of 28 months. Clinical evaluation was performed according to the International Knee Documentation Committee form, and sagittal knee laxity was measured with a KT-2000 arthrometer (MedMetric Corp, San Diego, CA). The MRI scans were obtained using a 0.2-T high-resolution MRI unit dedicated to the study of limbs, and the meniscal signal was graded according to a modified Crues classification. Overall, 77.3% of patients reported clinically good results. Loss of extension of < 5 degrees was detected in only 2 patients (9.1%). Three out of 22 patients showed clinical signs of meniscal retear. One of these patients had a second operation for a bucket-handle tear. The presence of a full-thickness rim at MRI evaluation, present in 10 patients (45.5%), did not correlate with the presence of clinical symptoms of retear. Instead, the 3 symptomatic patients presented a complete rim with a gap > 1 mm between the meniscal wall and the fragment of the posterior horn. This finding is believed to be a more reliable indicator for retear following meniscal repair. The low failure rate in this series suggests that an aggressive rehabilitation regimen may be prescribed without deleterious effects in subjects undergoing ACL reconstruction and concomitant meniscus repair.

Sonographic findings in haemodialysis-related chronic arthropathy.

In 33 subjects receiving long-term haemodialysis sonographic examination of shoulders, hips and knees was performed. Changes of both joints and periarticular soft tissues were found in 60 shoulders, 16 hips and 42 knees. In the shoulder besides the presence of tenosynovitis and bursitis, even significant thickening of rotator cuff and increased distance between capsule and bone in transascellar scan were found. Also, in the hip the distance between capsule and bone was significantly increased. In the knee effusion was present in 14 cases and synovial hypertrophy in 20. Articular femoral cartilage was significantly thinned. Results obtained suggest the hypothesis of the presence of an important inflammatory component in the pathogenesis of arthropathy related to haemodialytic treatment. The production of cytokines by mononuclear cells stimulated by beta-2 microglobulin may cause the inflammatory response. Sonographic findings of alterations in 42 symptomless joints show the importance of this diagnostic method to begin an early therapy.

[Technologic advances in magnetic resonance imaging: permanent low-field magnets dedicated to the study of the joints. Clinical results]. / Innovazioni tecnologiche nella Tomografia con Risonanza Magnetica: magneti permanenti con basso campo dedicati allo studio articolare. Risultati clinici.

Magnetic Resonance Imaging (MRI) has had a significant impact on the diagnosis of musculoskeletal conditions. Technologic advances in the last years allowed the development of cost-effective, compact and easy-to-install MR systems. After an early phase to optimize the units, a 14-month multicentric study was performed to define the possible clinical applications of the system. The obtained data are reported by the authors in the present study to assess the diagnostic accuracy of the new MR system for the study of the limbs. The system consists of an 0.2 T permanent unit, weighting 800 Kg, with a built-in radiofrequency shield and 10 mT/m gradients. October, 1992, to February, 1994, 2437 limbs examinations were carried out in patients whose age ranged 5 to 83 years. In 93% of cases, the exam was performed to study one joint, mostly the knee. MR diagnosis was verified in 311 patients, who were subsequently submitted to surgery. Quite satisfying overall results were obtained, particularly in case of knee traumas, comparable to those provided by units with more potentials. The particular structure of the magnet allowed the comfortable management of the pediatric, aged and acute patients. Nevertheless, in 3% of the investigated knee or elbow conditions, the examinations could not be performed due to technical limitations related to magnet size. In addition, the authors believe that a limited field of view (11-16 cm) does not allow accurate staging of the malignant lesions involving soft tissue and bone, which require a wider locoregional staging.

[Therapy of hepatic carcinoma by the intra-arterial injection of lipiodol, antineoplastic agents and gelfoam]. / Terapia degli epatocarcinomi mediante iniezione intra-arteriosa di lipiodol-antiblastici e gelfoam.

Chemoembolization by selective intra-arterial injection of lipiodol--chemotherapeutic agents (mitomycin and/or adriamycin)--followed by terminal embolization with gelfoam was performed on 20 inoperable patients with hepatic tumors: 13 hepatocellular carcinomas (HCC), 6 metastases from colorectal cancer, and one adenoma. A total of 29 embolizations were performed, 17 of them followed by gelfoam embolization. Significant decrease in tumor size or no tumor increase was shown in 8 patients--6 capsulated and well-limited HCC's, and 2 multinodular HCC's. Apart from occasional episodes of post-embolization syndrome (fever, vomit, abdominal pain), no significant complications were observed. Nine patients died at intervals ranging from 2 weeks to 37 months after the first embolization; in 6 patients the cause of death was not related to the advancing of the cancer, but to the complications of the underlying cirrhosis. In cirrhotic patients, damage to the rest of liver parenchyma can be limited by using superselective catheterization. Of the 6 patients with greater than 12 months follow-up, 4 are alive and 2 have died; 2 more patients are still alive 18 months after the first embolization. Finally, lipiodol was useful as radiopaque marker to detect lesion changes during the follow-up.