[Computerized tomography guided biopsy in the diagnosis of neoplastic and inflammatory lesions of the pelvis]. / La biopsia guidata con Tomografia Computerizzata nella diagnosi delle lesioni neoplastiche e infiammatorie del bacino.

PURPOSE: To assess the efficacy of percutaneous CT-guided biopsy in the diagnosis and therapeutic planning of neoplastic and flogistic diseases of the pelvis. MATERIAL AND METHODS: From July 1990 to December 1999 193 patients (113 males, 80 females: mean age 49, standard deviation 16) were submitted to CT-guided percutaneous biopsy of the pelvic region; 117 biopsies (61%) were performed at iliac, pubic and ischial segments and 76 (39%) at sacral region; 107 patients were admitted to the hospital and 86 were in clinic. Needles were 8 G (4 mm), 10 to 15 cm long. Approach to pelvic lesions was performed according to the specific site. Lesions of the lateral pelvic region have always been approached through the lateral surgical incision according to Enneking. Lesions of the posterior pelvic region have always been approached by the introduction of the needle along the posterior surgical incision according to Enneking. Lesions of the anterior region have always been approached through the anterior surgical incision according to Enneking. From July 1990 to May 1997 pelvic percutaneous biopsies have been carried out with a CT Sytec 3000. From May 1997 to December 1999 the device was replaced by a High Speed CTi. The introduction of spiral CT allowed reduction of performance mean time from 45 minutes (standard deviation 15) to 30 minutes (standard deviation 10). RESULTS: In 154 patients (80%) we observed a neoplastic, inflammatory or not classified degeneration. In 8 patients (4%) the retrieved material ended to be inadequate for a diagnosis. In 31 patients (16%) no disease was revealed at the histological examination. Such patients with negative histological examination have been kept under clinical and radiological control in the following period in order to verify the manifestation or the presence of an alteration previously not observed. On 31-3-2000 none of them had been submitted to a new percutaneous biopsy of the pelvic region. The overall mean accuracy has been 96% considering the negative patients as really negative. In 5 cases (2.6%) we have had complications represented by pain at the introduction and penetration site of the needle. DISCUSSION AND CONCLUSIONS: The choice of the needle, the approach to the lesion and the position of the patient are conditioned by the site of the tumor, its extension, the distance skin-neoplastic disease and by the respect of the incision lines of Enneking, in order not to complicate the job of the orthopaedic surgeon spreading tumoral cells outside the chosen surgical approach. The mean time of the procedure is 30 minutes (standard deviation 10). There are no absolute contraindications to percutaneous biopsy except the suspect or the presence of an hydatideal cyst. The risks have to be compared with those correlated with alternative methods or with the more concerning risk of a missed diagnosis. Complications in the literature range from 0% to 10%, the incidence varying according to the location; pain is the most frequent complication. Altogether the most negative event, although not a true complication, is the retrieval of an inadequate sample: the only drawback of percutaneous biopsy in comparison with incisional biopsy. The accuracy rate of percutaneous biopsy varies in relation to the involved anatomical region, to the pathological process, to the experience of the user, to the amount of the retrieved tissue and to the cooperation of the patient. Our experience shows that, in selected patients, percutaneous biopsy is a virtually safe and almost painless procedure which saves the patient from a surgical procedure in regional or general anestesia as for an incisional biopsy, and allows immediate planning and scheduling of a correct therapy for primitive or secondary neoplastic lesions.

[Computerized tomography assessment of femoral and tibial rotation in total knee prosthesis]. / Valutazione con Tomografia Computerizzata della rotazione delle componenti femorale e tibiale nell'artroprotesi totale del ginocchio.

PURPOSE: CT assessment of the axial deviation of the femoral and tibial prosthetic components in total knee arthroplasty. MATERIAL AND METHODS: January to July 1999, seventeen patients, 10 males and 7 females, mean age 66 years (standard deviation +/- 4) were examined after total knee arthroplasty. Exclusion criteria were prosthesis loosening and severe (equal or superior to 7 degrees) varus or valgus deviation. All patients were examined with knee radiography in the standing position completed by axial projections of patella and by CT scanning. We used a modification of Berger technique and carried out comparative CT scans extended lower limbs and acquisitions perpendicular to the mechanical axis of the knee, from the femoral supracondylar region down to the plane crossing the distal end of the tibial prosthetic component. Reference lines were then drawn electronically on given scanning planes to reckon the axial deviation of the femoral and tibial prosthetic components. RESULTS: Six patients, one female and 5 males, with normal rotational values of femoral and tibial prosthetic components presented no clinical symptoms. Eight patients, 4 females and 4 males, with abnormal values presented the following clinical symptoms: medial impingement, (incomplete) dislocation patella, and lateral instability. One female patient with a normal rotational value of femoral prosthetic component and an altered value of tibial prosthetic component presented medial impingement. Finally two patients, one female and one male, were absolutely asymptomatic although the rotational values of the two prosthetic components were beyond the normal range. CONCLUSIONS: Total knee arthroplasty is presently a standard treatment for many conditions involving this joint. There are several possible postoperative complications, namely fractures, dislocations (a)septic loosening and femoropatellar instability. The latter condition is the most frequent complication among implant failures and is caused by bad orientation of the femoral and tibial components on frontal and axial planes. We measured the orientation of the prosthetic components introducing a CT procedure which modifies the uniarticular with four scans introduced by Berger. The new method uses Berger's parameters and the CT study of both joints by means of Helical CT. With a single examination lasting less than 4 minutes and with the patient in a more comfortable position, we can obtain: 1) comparative and simultaneous assessment of the contralateral joint; 2) several scans to better define Berger's parameters and to accomplish measurement of the rotational deviation with higher precision and markedly decreasing the error margin. The analysis of the results confirms the international literature findings and especially the fundamental importance in positioning both prosthetic components within normal values, as emphasized by the relationship between the clinical symptoms and the rotational degree of the femoral and tibial prosthetic components.

[Significance of computerized tomography in the diagnosis of post-traumatic proximal carpal instability]. / L'importanza della Tomografia Computerizzata nella diagnosi dell'instabilità carpale post-traumatica prossimale.

INTRODUCTION: Proximal carpal instability is a painful condition characterized by early or late loss of radioulnar joint (RUJ) congruence not affecting the normal bone alignment of the two carpal rows. The joint incongruence or (incomplete) dislocation which leads to proximal instability is caused by many traumatic and nontraumatic events. The diagnosis of (incomplete) dislocation of the distal RUJ may be extremely difficult to make at conventional radiography because such injuries can be seen only when the lateral joint projection is perfect; otherwise the diagnosis is not reliable. CT is the only imaging tool diagnosing the grade of distal RUJ congruence independent of the examination technique. MATERIAL AND METHODS: We studied the radiocarpal complex conditions leading to proximal instability at the Rizzoli Orthopedic Institute from December, 1995, through December, 1997. In all, 389 cases were seen, 376 from trauma and 13 of nontraumatic origin. Each injury was studied with conventional radiography, CT, and MRI. Radiography was performed in two projections, namely the posteroanterior one with hand extension and the lateral one with the forearm in neutral position and the elbow bent at 90 degrees; the projections were repeated whenever a cast brace was applied. Unenhanced CT was performed for comparison with the patient prone and the forearm and wrist in prone and neutral position, as well as with the patient, forearm and wrist supine. Three criteria of electronic image processing were adopted for the RUJ studies in the 3 projections: radioulnar lines, congruence, and epicenter. MRI was always performed after conventional radiography and CT. Only the involved radiocarpal region was studied; coronal, axial and sagittal images were acquired with T2-weighted GE and T1-weighted SE sequences. RESULTS: Proximal instability was found in 17 of 389 patients; it was early in 13 and late in 4 of them. The comparison of radiographic and CT results showed that the former method is unreliable, with 53% false negatives. Pain, a cast brace, congenital or acquired deformities of distal radius and ulna and patient mispositioning by the radiology technician can change the rotation of the forearm, wrist and hand and make a perfect laterolateral projection in neutral position unfeasible, which affects the radiographic diagnosis. Conversely, CT showed its extreme efficacy in assessing the distal RUJ congruence with no false negatives independent of the RUJ rotation and of instability type and grade. CONCLUSIONS: Conventional radiography is a poorly reliable tool for the diagnosis of joint incongruence and its grade. In contrast, CT can diagnose a RUJ (incomplete) dislocation easily and unquestionably, thanks to its axial capabilities, even when adequate radiographic studies would be unfeasible. If the anteroposterior projection of the radiocarpal complex shows a congenital or acquired deformity of distal radius, the lateral projection can be skipped and a CT scan in prone, neutral and supine position performed. The 3 CT criteria quantify incongruence type and grade, and also demonstrate the position of maximum incongruence and its decrease by position. The comparative study of the radiocarpal region makes CT a very useful and valuable tool in congenital instability because its allows the assessment of contralateral radioulnar congruence too. MRI is very useful in the diagnosis of injury or degeneration of the fibrocartilage complex, namely in patients with no bone changes at conventional radiography.

[Significance of three-compartment digitalized arthrography in the diagnosis of post-traumatic instability of the radiocarpal complex]. / L'importanza dell'artrografia tricompartimentale digitalizzata nella diagnosi dell'instabilità post-traumatica del complesso radio-carpico.

INTRODUCTION: The radiocarpal complex is the structure formed by the distal radioulnar, radiocarpal and midcarpal joints; these joints are compartments, each anatomically separated from the other. An appropriate arthrographic study with three-compartment injection better demonstrates the capsuloligamentous structures than conventional radiography. The diagnosis of any condition in this complex may therefore be easier to make. MATERIAL AND METHODS: From January 1993 to December 1996, twenty-six patients with mild to moderate wrist and carpal sprain and previously examined with radiography, were submitted to digital three-compartment arthrography at the Imaging Diagnostic Service of the Rizzoli Orthopedic Institute. Of 17 patients with previous radiographic diagnosis of scapholunar diastasis, 1 patient had a negative radiographic picture, 15 had an incomplete tear of the scapholunar ligament and 1 a double injury of the scapholunar and triquetro-lunar ligaments. Of 10 patients with mild to moderate triquetro-lunar diastasis, 8 had and arthrographic picture of pyramido-lunar ligament injury, 1 had a double injury of the triquetro-lunar and scapholunar ligaments and another one of triangular fibrocartilage complex injury. RESULTS: Three-compartment contrast agent injection permitted the diagnosis of interruptions between the different compartments and more injuries of scapholunar and triquetro-lunar ligaments than single compartment injection. We examined 27 patients with small arch injuries with three-compartment digital arthrography and found scapholunar diastasis in 17 (63%) and triquetro-lunar diastasis in 10 (37%). In the first group of 17 patients, three-compartment arthography demonstrated more scapholunar ligament injuries (13 cases) than single compartment injection; image subtraction, allowed by the digital technique, showed 2 injuries not visible otherwise. Injuries of the scapholunar and triquetro-lunar ligaments were demonstrated with and without digital subtraction. One patient had no ligament injury. In the other group of 10 patients, three-compartment arthrography showed more triquetro-lunar ligament injuries (6 cases) than single compartment injection; image subtraction demonstrated 2 injuries not visible otherwise in this group too. Injuries of the scapholunar and triquetro-lunar ligaments were demonstrated with and without digital subtraction. The injury of triangular fibrocartilage and contrast agent leak into soft tissues were shown in one patient with the injection of the distal radioulnar compartment alone, regardless of image subtraction. CONCLUSIONS: Arthrography, combined with conventional static and dynamic radiography, increases the detection rate of capsuloligament joint defects in the wrist-carpal complex. The three-compartment digital technique combines the advantages of fluoroscopic monitoring and videorecording and allows real time imaging of the contrast agent flow during injection in different compartments. Moreover, the digital technique permits the complete study of all joints in a single session, while image subtraction reveals even minimal ligament changes. This technique becomes therefore a fundamental tool for surgical planning.

The biological problems of total hip arthroplasty.

Biological phenomena are the principal agents in triggering hip prosthesis aseptic loosening. The authors report the results of "in vivo" and "in vitro" and Raman-laser experimental tests, which confirm the validity of the ceramic-ceramic combination in relation to the amount of wear and biocompatibility of friction materials.

[Traditional radiology in the assessment of posttraumatic carpal instability]. / La radiologia tradizionale nella valutazione dell'instabilità carpale post-traumatica.

INTRODUCTION: Carpal instability is a painful posttraumatic syndrome with early or late loss of the normal alignment of the carpal bones, which can be caused by a variety of injuries, from minor sprain to major fracture-dislocation of the carpal-wrist complex. If the trauma causing instability is a fracture, a severe dislocation or a fracture-dislocation, the radiographic diagnosis is not particularly difficult. The morphologic and dynamic complexity of the carpal region represents, instead, a major obstacle in the radiologic diagnosis of mild or moderate sprains because the morphologic alterations on standard static views are minimal or absent in these conditions. MATERIALS AND METHODS: We reviewed 214 injuries causing posttraumatic carpal instability including both the cases classified by the Data Analysis Center of the Istituto Ortopedico Rizzoli as carpal dislocations and fracture-dislocations from January, 1975, to July, 1996, and the more recent cases directly observed at our Casualty Clinic. In the former cases, we reviewed only the available images, while our patients were examined with comparative standard and under stress or dynamic views. RESULTS: Of 214 lesions causing posttraumatic carpal instability, 43 along the great arch were classified as severe because they were easily detectable on standard films and 171 along the small arch were classified as mild because slight/no abnormalities were detected on standard static views. Only dynamic imaging showed posttraumatic carpal instability demonstrating the integrity of the ligaments and of the carpal hinges, as well as gaps or asymmetry not detected on static views. CONCLUSIONS: We suggest the systematic use of dynamic imaging in the cases where static findings are negative or poor, in the patients with a painful wrist after an apparently minor sprain. Missed or delayed diagnoses are thus reduced, as well as the consequent joint incongruity and/or chronic subluxation which may severely impair these patients.

A study of the mechanical and biological behavior of bioceramic hip arthroplasty followed-up after more than 10 years.

The authors report the results obtained in three experiments conducted on hip arthroplasty with ceramic-ceramic coupling and the evaluation of clinical follow-ups carried out on cemented bioceramic arthroplasty more than 10 years after surgery. A first test consisted in the "in vivo" study of alumina powder injected in the joints of four pigs with the purpose of verifying the biocompatibility of the compound. A second test involved the experimental evaluation of "in vitro" wear of the alumina as compared to other types of coupling, and confirmed the very low tendency of wear in alumina. A third spectroscopic study conducted using a Raman laser demonstrated the absolute biostability of the surface of bioceramic material. A retrospective clinical study was conducted in order to verify laboratory data in 83 cemented bioceramic arthroplasties followed-up more than 10 years after surgery and of which 92% obtained good clinical results.

Morphometric and microanalytical analyses of alumina wear particles in hip prostheses.

We analysed tissues harvested during 24 retrievals of hip joint prostheses, with one or both articular components made of alumina. We describe the morphology of wear particles, measure their size and analyse their chemical composition. We relate histopathological aspects to the parameters that characterize ceramic wear particles, and notice that tissue reaction relates to the physical aspect and amount of wear debris and does not necessarily depend on their chemical composition.

The results of the surgical treatment of breakage of the rotator cuff.

Sixteen patients affected with rotator cuff tears were treated by surgical repair and anterior acromioplasty, using superior of anteromedial approaches. The authors believe that acute and chronic massive ruptures causing significant functional failure must be surgically treated. Good results may be obtained if impingement signs of arthropathy are absent at surgery.

Syringomyelic arthropathy: a description of two cases and a review of the literature.

Neurogenous arthropatHy is a rare disease. Nonetheless, every orthopaedist will sooner or later be faced with the arthropathy before the neurologic disease has been diagnosed. The authors report their study on two cases of syringomyelic arthropathy, repropose its anatomopathological, clinical and radiographic features, and discuss the etiopathogenesis, differential diagnosis and treatment of the disease.

An evaluation of the "quoad vitam" prognosis in the elderly patient with medial fracture of the femoral neck.

The authors analyzed 425 consecutive cases of medial fracture of the femoral neck with the purpose of establishing a simple and practical system, and one which is easy to use, in order to evaluate this type of lesion and to compare different series of cases. Based on these criteria the death rate occurring intra-hospital and 6 months after trauma, the influence of the age factor, the type of anesthesia used and the type of treatment carried out, were evaluated. The results were as follows: The classification devised by the American Society of Anesthesiology continues to be an effective system for the evaluation of vital risk. The death rate was always directly related to age, and it was not influenced by either the type of anesthesia or the type of surgery used; however, it doubled when non-surgical treatment was used.

Chondrosarcoma of the hand and foot.

Among possible localizations of chondrosarcoma of the limbs, the hand and foot represent the rarest sites. Five-hundred six cases of chondrosarcoma have been observed at the Tumor Center of the Rizzoli Orthopaedic Institute. Of these, 4 were localized in the hand and 10 in the foot. The authors compared their cases with those reported in the international literature. The authors emphasize the particular aspects of the tumor when localized in these sites which may be responsible for late diagnosis and difficulty in differential diagnosis involving synovial chondromatosis and, above all, chondroma, from which chondrosarcoma may originate.

[Radiographic pictures of foot localizations of Ewing's sarcoma]. / Quadri radiografici delle localizzazioni al piede del sarcoma di Ewing.

Ewing's Sarcoma (ES) is the most frequent malignant bone tumor of the foot. The radiological picture is characterized, in 14 patients, by a pure osteolytic lesion (9 cases) or by a mixed one (5 cases); the interruption of the cortical bone and swelling of the soft tissues were always present; the periostal reaction was occasional. The radiological aspects cannot be considered typical of the ES and it is suggested that biopsies should always be performed in the presence of a structural alteration of the bone.

Monostotic fibrous dysplasia of the spine: case report.

A case of monostotic fibrous dysplasia of the spine is presented. It was referred to us after a history of 3 years' pain. The site of the anomaly is so exceptional that it invited comparison with the six other cases described in the literature. This comparison produced resemblances which differentiate this particular type of monostotic fibrous dysplasia form that located at other sites, both in its clinical aspects and its radiographic appearances.

[Radiographic aspects of metastasis to the foot]. / Aspetti radiografici delle localizzazioni metastatiche al piede.

The authors present the radiographical features in 8 cases with metastatic tumors to the foot bones. Seven of them have been histologically confirmed. In 4 cases the tumor was monostotic and mainly osteolytic. In the other 4 the neoplasia, having osteolytic or osteoblastic appearance, involved multiple contiguous bones.