Soft tissue foreign bodies: A training manual for sonographic diagnosis and guided removal.

Sonography provides excellent detection, localization, and characterization of soft-tissue foreign bodies. Ultrasound guided foreign body removal is a safe and highly successful minimally invasive procedure that facilitates effective treatment and avoidance of complications in patients with soft tissue foreign bodies. Focused laboratory training is critical to successful implementation of a sonographic foreign body management practice.

Percutaneous Doxycycline Treatment of Juxtaphyseal Aneurysmal Bone Cysts.

BACKGROUND: A recurrence rate of 19% to 23% has been reported in juxtaphyseal aneurysmal bone cysts (ABC) without en bloc resection or amputation. No percutaneous surgical techniques or drug treatments have demonstrated consistent bone healing with normal physeal growth and a recurrence rate of <19%. Doxycycline has properties that may make it an appropriate agent for percutaneous treatment of juxtaphyseal ABC in skeletally immature patients. METHODS: We retrospectively reviewed 16 patients who underwent percutaneous treatment of ABCs with doxycycline from 2006 to 2011. The mean age was 7.1 years (range, 2 to 15 y). There were 16 treatment locations: humerus (9), tibia (3), fibula (2), femur (1), and ulna (1). Sixteen patients completed treatment involving 102 treatment sessions (2 to 14 sessions per patient). Treatment response was evaluated radiographically by measuring the lytic component, thickness of involved cortex, and signs of bony remodeling, and evidence of physeal growth arrest. Recurrence was indicated by new areas of lytic destruction after completion of treatment. The minimum follow-up was 18 months (mean, 39 mo). RESULTS: All 16 patients demonstrated reduction in lytic destruction, bony healing, and bony remodeling. One patient demonstrated recurrent minimal lytic destruction after 20 months of observation. Seven patients (7/16, 44%) demonstrated physeal ABC involvement; 5 of 7 patients healed with a physeal bone bridge, all ≤15% of the physeal surface area, 1 with mild central physeal deformity. All patients with focal transphyseal ABC involvement (4/4, 100%) demonstrated focal bone bridge after treatment. No patient had diffuse physeal growth arrest; only patients with intraphyseal or transphyseal ABC involvement had focal physeal growth arrest. CONCLUSIONS: In this series, patients undergoing percutaneous doxycycline treatment of juxtaphyseal ABCs demonstrated ABC healing and a recurrence rate of 6% at >18 months. Patients without physeal ABC involvement demonstrated no evidence of physeal growth arrest.

Ultrasound-guided corticosteroid injection of the subtalar joint for treatment of juvenile idiopathic arthritis.

BACKGROUND: The subtalar joint is commonly affected in children with juvenile idiopathic arthritis and is challenging to treat percutaneously. OBJECTIVE: To describe the technique for treating the subtalar joint with US-guided corticosteroid injections in children and young adults with juvenile idiopathic arthritis and to evaluate the safety of the treatment. MATERIALS AND METHODS: We retrospectively analyzed 122 patients (age 15 months-29 years) with juvenile idiopathic arthritis who were referred by a pediatric rheumatologist for corticosteroid injection therapy for symptoms related to the hindfoot or ankle. In these patients the diseased subtalar joint was targeted for therapy, often in conjunction with adjacent affected joints or tendon sheaths of the ankle. We used a protocol based on age, weight and joint for triamcinolone hexacetonide or triamcinolone acetonide dose prescription. We describe the technique for successful treatment of the subtalar joint. RESULTS: A total of 241 subtalar joint corticosteroid injections were performed under US guidance, including 68 repeat injections for recurrent symptoms in 26 of the 122 children and young adults. The average time interval between repeat injections was 24.8 months (range 2.2-130.7 months, median 14.2 months). Subcutaneous tissue atrophy and skin hypopigmentation were the primary complications observed. These complications occurred in 3.9% of the injections. CONCLUSION: With appropriate training and practice, the subtalar joint can be reliably and safely targeted with US-guided corticosteroid injection to treat symptoms related to juvenile idiopathic arthritis.

Percutaneous transcervical thoracic duct embolization for treatment of a cervical lymphocele following anterior spinal fusion: a case report.

Thoracic duct injury is an uncommon complication of neck dissection and cervical spinal surgery that is associated with significant morbidity. The authors describe an unusual case of thoracic duct injury during anterior spinal fusion resulting in a large prevertebral lymphocele presenting with dysphagia, respiratory distress, and chyloptysis. Surgical closure of the lymphocele was unsuccessful, and percutaneous drainage and sclerotherapy was performed. A large thoracic duct branch communicating with the lymphocele became evident during sclerotherapy, and embolization of the duct was performed via a percutaneous transcervical approach. Symptoms immediately resolved, and the patient remained asymptomatic at 6-month follow-up.

Percutaneous doxycycline treatment of aneurysmal bone cysts with low recurrence rate: a preliminary report.

BACKGROUND: Aneurysmal bone cyst (ABC) has a recurrence rate of between 12% and 71% without en bloc resection or amputation. There is no percutaneous ABC treatment drug regimen demonstrating consistent evidence of bone healing with recurrence of < 12%. Doxycycline has properties that may make it appropriate for percutaneous treatment. QUESTIONS/PURPOSES: We therefore asked: (1) Is there reduction in ABC lytic cyst volume with injectable doxycycline? (2) Is it associated with thickening of involved bony cortex? (3) Is the recurrence rate after percutaneous treatment < 12%? METHODS: We retrospectively reviewed 20 patients who underwent percutaneous treatment of ABCs with doxycycline from 2006 to 2010. The mean age was 10 years (range, 3-18 years). There were 21 treatment locations: humerus (six), spine (five), clavicle (two), fibula (one), femur (two), ulna (two), tibia (two), and scapula (one). Twenty patients completed treatment involving 118 treatment sessions (two to 14 sessions per patient). Treatment response was evaluated radiographically by measuring the lytic component and thickness of involved cortex. Recurrence was indicated by new areas of lytic destruction after completion of treatment. The minimum followup was 24 months (mean, 38 months). RESULTS: Twenty of 20 patients demonstrated reduction in lytic destruction and bony healing. All patients demonstrated cortical thickening. One patient demonstrated recurrent minimal lytic destruction after 20 months of observation. CONCLUSIONS: In this series, patients undergoing percutaneous doxycycline treatment of ABCs demonstrated a healing response and a recurrence rate of 5% at more than 24 months.

Ultrasound-guided musculoskeletal procedures in children.

Ultrasound is an excellent tool to evaluate many pediatric musculoskeletal conditions. It may be used for both diagnosis and for guidance for therapeutic procedures. With US, the radiologist can readily evaluate the contralateral side for comparison. No sedation is typically required and ionizing radiation is avoided. Real-time information is obtained with US and the portability of US allows for the performance of bedside interventions in children who cannot be transported or are clinically unstable. Limitations of US compared with MRI and CT include limited field of view, inability to evaluate the bone marrow and user dependence of image and exam quality. In this article, we discuss common US-guided musculoskeletal procedures in children, including hip aspiration, joint injection, soft-tissue biopsy and foreign body removal.

Ultrasound-guided corticosteroid injection therapy for juvenile idiopathic arthritis: 12-year care experience.

BACKGROUND: Intra-articular corticosteroid injections are a safe and effective treatment for patients with juvenile idiopathic arthritis. The potential scope of care in ultrasound-guided corticosteroid therapy in children and a joint-based corticosteroid dose protocol designed to optimize interdisciplinary care are not found in the current literature. OBJECTIVE: The purpose of this study was to report the spectrum of care, technique and safety of ultrasound-guided corticosteroid injection therapy in patients with juvenile idiopathic arthritis and to propose an age-weight-joint-based corticosteroid dose protocol. MATERIALS AND METHODS: A retrospective analysis was performed of 198 patients (ages 21 months to 28 years) referred for treatment of juvenile idiopathic arthritis with corticosteroid therapy. Symptomatic joints and tendon sheaths were treated as prescribed by the referring rheumatologist. An age-weight-joint-based dose protocol was developed and utilized for corticosteroid dose prescription. RESULTS: A total of 1,444 corticosteroid injections (1,340 joints, 104 tendon sheaths) were performed under US guidance. Injection sites included small, medium and large appendicular skeletal joints (upper extremity 497, lower extremity 837) and six temporomandibular joints. For patients with recurrent symptoms, 414 repeat injections were performed, with an average time interval of 17.7 months (range, 0.5-101.5 months) between injections. Complications occurred in 2.6% of injections and included subcutaneous tissue atrophy, skin hypopigmentation, erythema and pruritis. CONCLUSION: US-guided corticosteroid injection therapy provides dynamic, precise and safe treatment of a broad spectrum of joints and tendon sheaths throughout the entire pediatric musculoskeletal system. An age-weight-joint-based corticosteroid dose protocol is effective and integral to interdisciplinary care of patients with juvenile idiopathic arthritis.

Percutaneous drainage and ablation as first line therapy for macrocystic and microcystic orbital lymphatic malformations.

PURPOSE: To review the management of orbital lymphangiomas and to propose a new treatment for both macrocystic and microcystic lymphatic malformations of the orbit. METHODS: A retrospective case series of all patients from the authors' practice from 2001 to the present who met the histopathologic and/or diagnostic imaging criteria for orbital lymphatic malformation was reviewed. Lymphatic malformation was diagnosed if there was a multilobulated pattern on CT or a cystic internal structure on ultrasonography. In patients that were treated, macrocysts (>1 cm) were treated with dual-drug chemoablation (sequential intracystic sodium tetradecyl sulfate and ethanol); doxycycline injections were used for microcysts. The goal of treatment was complete cyst ablation documented by ultrasonography or MRI. RESULTS: Twenty patients met the inclusion criteria. They were separated in 3 groups based on the anatomical location of the lymphatic malformation: deep, superficial, or combined. Deep orbital lymphatic malformation presented in 14 patients (70%), superficial presented in 4 patients (20%), and both deep and superficial presented in 2 patients (10%). Thirteen of the 20 patients underwent percutaneous sclerotherapy. Of those treated, 7 patients (53.8%) had lymphatic malformations (LM), while 6 patients (46.2%) had venous-lymphatic malformations (VLMs). The average number of treatments required to achieve complete cyst ablation in patients with LM was 1.7. The average number of treatments required for patients with VLM was 3.0; however, some of these patients continue to have the venous component of their lesions treated. Clinically, all treated patients maintained or improved an average of one Snellen line (-0.16 decimal Snellen equivalent) from their preoperative visual acuity to their last recorded follow-up visit. There was a mean reduction in proptosis of 2.4 mm (p - 0.003, confidence interval [CI] 0.838 to 3.962), which was statistically significant. There were no recurrences (0%) in patients who completed treatment with cyst ablation (n - 8) at an average follow-up period of 43 months (range 6-96, standard deviation 30). There were no data available as to the recurrence status of one patient. Four patients were still undergoing treatment for a venous component at the time of this review. CONCLUSIONS: Percutaneous sclerotherapy provides a safe and effective treatment for both macrocystic and microcystic orbital lymphatic malformations as a primary treatment or for recurrence after surgical intervention.

Precervical myositis ossificans in an infant secondary to child abuse.

We present a 10-week-old girl with myositis ossificans circumscripta (MO) of the neck secondary to nonaccidental trauma. This condition is rarely seen in infants; furthermore, the majority of MO lesions develop in the extremities rather than the head and neck region. We will detail the US-guided biopsy technique used in our case, in addition to discussing the characteristic imaging and pathological findings of MO to assist in the diagnosis and successful treatment of this condition.

Difficult central venous access removal: case reports of the use of endovascular snare shearing of endothelialized tetherings.

Although a fibrin sheath occurs in most long-standing central venous catheters, they do not typically interfere with complete removal of the catheter. We present 2 cases of long-standing catheters that could not be removed with simple surgical techniques because of endotheliazation via fibrous attachments to the venous wall. Both catheters were successfully removed using a modified snare technique through the right femoral vein.

Self-embedding behavior: a new primary care challenge.

OBJECTIVE: The goal of this study was to define self-embedding behavior (SEB), develop a clinical profile of adolescents who engage in SEB, and emphasize the importance of rapid, targeted, and effective identification and intervention. METHODS: As part of a retrospective study with a database evaluating 600 patients percutaneously treated for soft-tissue foreign body removal, adolescents were identified with self-embedded soft-tissue foreign bodies. We describe patients' gender, age, and psychiatric diagnoses; SEB age of onset, frequency, and self-reported reasons; and the number, type, location of, and removal technique for objects. RESULTS: Eleven patients (9 females) who engaged in SEB were identified. Ten of the 11 patients were members of a group home or psychiatric facility at the time they engaged in SEB. All patients had previous and multiple psychiatric diagnoses. SEB mean age-of-onset was 16 years, and mean number of SEB episodes per patient was 1.9. The most common self-reported purpose for SEB was suicidal ideation (6 of 8 [75%]) versus nonsuicidal ideation (2 of 8 [25%]), with 3 cases lacking this documentation. The mean number of objects embedded in a single episode was 2.4, usually composed of metal and embedded in the arm. Seventy-six foreign bodies were percutaneously removed (using ultrasound or fluoroscopic guidance), including metal, glass, wood, plastic, graphite, and crayon. CONCLUSIONS: SEB is an extreme form of self-injury requiring aggressive and timely interdisciplinary assessment and treatment. An understanding of SEB allows medical professionals to pursue rapid, targeted, and effective intervention to interrupt the cycle of self-harm and institute appropriate long-term therapy.

Self-embedding behavior: radiologic management of self-inserted soft-tissue foreign bodies.

PURPOSE: To report on a series of self-embedding behavior (SEB), demonstrate the effectiveness and clinical effect of image-guided foreign body removal (IGFBR) in the treatment of embedded soft-tissue foreign bodies (STFBs), and evaluate the role of the radiologist in the clinical management of SEB. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board. From a database of 600 patients treated with IGFBR with ultrasonographic (US) and/or fluoroscopic guidance, self-injury was identified in 11 (1.8%) mainly adolescent patients with a mean age of 16 years (age range, 14-18 years). Evaluated data included number of foreign bodies; number of repeat episodes of foreign body insertion; location, type, and size of foreign body; incision size; imaging modality; and success or failure of foreign body removal. RESULTS: Seventy-six foreign bodies were inserted into the arm (n = 69), neck (n = 4), ankle (n = 1), foot (n = 1), or hand (n = 1) in the 11 patients. The number of STFBs per case ranged from one to 15. Foreign body types included metal (n = 40), plastic (n = 15), graphite (n = 12), glass (n = 4), wood (n = 3), crayon (n = 1), and stone (n = 1). STFB dimensions were 2.5-160.0 mm in length by 0.25-3.0 mm in thickness. Sixty-eight of the 76 STFBs were removed in the interventional radiology section. Incision lengths ranged from 4 to 8 mm (mean, 6 mm). The STFBs were removed with US guidance (n = 43), fluoroscopic guidance (n = 15), or a combination of the two modalities (n = 10). IGFBR was successful in all 68 cases, without complications. CONCLUSION: Greater awareness of SEB may result in radiologists being the first physicians to identify SEB and rapidly mobilize an interdisciplinary team for early and effective intervention and treatment. Percutaneous radiologic treatment of self-imbedded STFBs is safe, precise, and effective for radiopaque and nonradiopaque foreign bodies.

Percutaneous treatment of lymphatic malformations.

OBJECTIVE: The aim of this study is to investigate a new treatment regimen for macrocystic and microcystic lymphatic malformations (LM) of the head and neck. STUDY DESIGN: The study represents a retrospective review of outcomes from new percutaneous treatments for lymphatic malformations. SUBJECTS AND METHODS: Thirty-one patients (age range, 2 days to 51 years of age) underwent percutaneous treatment for LM of the head and neck from 2001 to 2007. The LM involved the orbit, ear, parotid gland, face, and neck. Twenty-seven patients underwent primary treatment of LM; 4 were treated for recurrence after operative resection. Macrocysts (>or=1 cm) were treated with dual-drug chemoablation (sequential intracystic sodium tetradecyl sulfate and ethanol); doxycycline was used for microcysts. Macrocysts and microcysts were treated after complete cyst aspiration with sonographic guidance. Fifty-four macrocysts and 125 microcysts were treated. The goal of treatment was complete cyst ablation documented by sonography or MR imaging. RESULTS: Mean number of treatments was 1.7 per patient; mean number of treatments for macrocysts was 1.1; mean treatments for microcysts was 1.7. Ablation efficacy was 179 of 179 (100%) cysts. Effective cyst ablation achieved effective clinical control with resolution of the external mass appearance. Treatments included massive head and neck mixed LM and cysts surrounding the facial nerve and brachial plexus. Infection occurred in 2 (6%) of 31 patients. No patient experienced postprocedural pain, skin necrosis, neuropathy, skin retraction, or myoglobinuria. CONCLUSION: Percutaneous sclerotherapy provides effective treatment for macrocystic and microcystic LM as primary treatment or for recurrence after surgical resection.

Percutaneous ultrasound-guided intraorbital foreign body removal.

Percutaneous ultrasound-guided intraorbital foreign body removal was successfully performed for removal of an intraorbital wooden foreign body. A 13-month-old boy presented with left periorbital cellulitis, which developed 3 days after a fall from an all-terrain vehicle. Orbital CT showed preseptal and postseptal orbital cellulitis, and an 11 x 2 mm linear foreign body in the medial compartment of the left eye. Surgical exploration of the left eye was performed, with no foreign body identified. Following surgery, diagnostic sonography demonstrated a linear foreign body adjacent to the medial rectus muscle, with sonographic characteristics compatible with wood. The percutaneous procedure was performed with intravenous deep sedation. With sonographic guidance, a Hartmann forceps was advanced in the medial soft tissues of the orbit, and the foreign body was removed intact. Ophthalmologic follow-up over 6 months revealed no evidence of visual loss, nerve injury, or impairment of extraocular muscle function.

Definitive percutaneous treatment of lymphatic malformations of the trunk and extremities.

PURPOSE: The aim of this study is to investigate a new treatment regimen for macrocystic and microcystic lymphatic malformations (LMs) of the trunk and extremities. METHODS: Sixteen patients (aged 2 months-22 years) underwent percutaneous treatment for LM of the trunk and extremities from 2002 to 2007. The LM involved the arm, leg, axilla, chest, abdomen, scrotum, and penis. Eleven patients underwent primary treatment of LM; 5 were treated for recurrence after prior operative resection. Macrocysts (>or=1 cm) were treated with dual-drug chemoablation (sequential intracystic sodium tetradecyl sulfate and ethanol); doxycycline was used for microcysts. Macrocysts and microcysts were treated after complete cyst aspiration using sonographic guidance. Twenty-four macrocysts and 103 microcysts were treated. The goal of treatment was complete cyst ablation documented by sonography or magnetic resonance imaging. RESULTS: The mean number of treatments was 1.7 per patient; the mean number of treatments for macrocysts was 1.3 and for microcysts was 1.7. Ablation efficacy was 100% (127/127 cysts). Treatments included massive intraperitoneal cysts and cysts surrounding the adventitia of the brachial artery and brachial nerve. Infection occurred in 2 (13%) of 16 patients. No patient experienced postprocedural pain, skin necrosis, neuropathy, bowel obstruction, skin retraction, or myoglobinuria. CONCLUSIONS: Percutaneous sclerotherapy provides effective treatment for macrocystic and microcystic LM as primary treatment or for recurrence after surgical resection.

Age-dependent dynamic sonographic measurement of pediatric clubfoot.

BACKGROUND: US shows promise in evaluating clubfeet. In order to assess responses to therapy, the measurements of normal feet and clubfeet must be known. OBJECTIVE: To investigate the role of US measurement in quantitatively evaluating normal feet and clubfeet in children, and to assess changes in these feet with age. MATERIALS AND METHODS: Patients <1 year old with unilateral or bilateral clubfoot deformity underwent US examination of the foot with specific attention to the medial malleolar to navicular (MMN) distance. Measurements were made in neutral and full adduction positions, and in the abduction position simulating the Ponseti maneuver. Children undergoing US for other reasons had the same imaging performed and served as controls. RESULTS: A total of 127 feet in 66 children were evaluated (20 children had bilateral clubfeet, 25 had unilateral clubfoot, and 21 had normal feet). Clubfeet had significantly (P < 0.001) lower MMN measurements at all three positions than control feet. These distances increased with patient age for both normal feet and clubfeet, but the rate of increase was less for clubfeet. CONCLUSION: Normal feet and clubfeet exhibit marked differences in MMN distances, as well as differences in rate of change over time. By understanding the age-dependent variability of normal feet and clubfeet, dynamic sonography can help assess clubfoot anatomy and could help to assess the effect of treatment interventions.

Focused dynamic sonographic examination of the congenital clubfoot.

BACKGROUND: US readily demonstrates cartilaginous structures, and static sonography has shown potential in evaluating clubfoot deformity. OBJECTIVE: To investigate the potential of dynamic sonography in the evaluation of the congenital clubfoot. MATERIALS AND METHODS: Sonography was used for static and dynamic stress evaluation of 13 clubfeet and 35 normal feet in 24 patients (ages 0-32 weeks). Dynamic foot sonography was performed using a single-operator bimanual scanning technique. The examination involved coronal oblique evaluation of the medial malleolar-navicular (MMN) distance and the calcaneocuboid relationship, sagittal evaluation of the talonavicular relationship, and transverse evaluation of navicular subluxation, rotation, and deformation. Dynamic abduction/adduction stress maneuvers were performed, measured by the MMN. RESULTS: The clubfoot "gristle" is a consistent, measurable soft-tissue landmark in clubfeet, connecting the medial malleolus to the medial navicular and talus. Mean MMN distances in clubfeet in the neutral position and abduction were significantly different from these distances in the normal paired foot (differences of 8.7 mm neutral position and 7.94 mm abduction), as compared to bilateral normal feet (differences of 0.98 mm neutral position and 1.43 mm abduction). Navicular subluxation showed good correlation between highly deformed and subluxated navicular bones and a tight medial clubfoot complex. CONCLUSIONS: Focused dynamic foot sonography is useful in providing a specific and detailed functional preoperative and/or postoperative assessment of the congenital clubfoot.