Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

OBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle.

OBJECTIVES: Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval. RESULTS: A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement. CONCLUSION: According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton's neuroma, particularly using platelet-rich plasma and corticosteroids, respectively. KEY POINTS: • The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle. • Strong consensus was obtained for all statements. • The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton's neuroma and PRP for plantar fasciitis.

Presacral and intrathoracic extramedullary hematopoiesis in a patient with ß thalassemia minor.

Extramedullary hematopoiesis (EMH) is a rare disease characterized by the presence of hematopoietic elements outside the bone marrow as a compensatory phenomenon in several hematological diseases, including thalassemia. We report a 64-year-old man with epigastric pain of 3-months' duration radiated to the back. Imaging workup showed multiple paravertebral, retrosternal and presacral masses. Cytology findings obtained by CT-guided FNAC were compatible with the diagnosis of EMH. Peripheral blood smear confirmed the presence of ß-thalassemia.

Rupture of the Posterior Cruciate Ligament: Preoperative and Postoperative Assessment.

Posterior cruciate ligament (PCL) ruptures are not common, but reconstruction is increasing because PCL-deficient knees are prone to develop osteoarthritis. Preoperative MRI may confirm a total or partial disruption of PCL fibers. An overstretched PCL is often mistaken for an intact PCL while the knee is functionally PCL deficient, resulting in false-negative MRI reports. Posterior translation of the medial condyle is a useful indirect sign on imaging. Preoperative stress radiographs are used to quantify the degree of PCL deficiency, and posterior translation determines whether to treat conservatively or with surgery. Early postoperative imaging is performed to evaluate tunnel placement and fixation devices. Late postoperative imaging is performed to assess graft rupture, arthrofibrosis, or tunnel widening. Pre- and postoperative imaging plays an important part in planning and treating functionally PCL-deficient knees and PCL ruptures.

Imaging of posterior cruciate ligament (PCL) reconstruction: normal postsurgical appearance and complications.

This article reviews the normal postsurgical anatomy and appearance of PCL reconstructions on MDCT and MRI with the different operative techniques considering the type of tibial fixation, use of a single or double bundle, type of tendon graft and the fixation material. Tunnel positioning, appearance of the ligament graft and findings at the donor site are considered. Imaging signs of PCL graft failure and its possible causes are discussed. Imaging manifestations of other potential complications of both the PCL graft and donor sites are described, such as laxity, impingement, arthrofibrosis, ganglion cyst formation or complications related to the fixation material.

Facelift approach for neck dissection in squamous cell carcinoma of the lateral border of the tongue: application of this novel aesthetic technique in head and neck oncologic surgery.

The scars produced by the surgical approaches commonly used for neck dissection in patients with malignant tumors of the head and neck are generally very evident and unaesthetic, especially when performed on young patients or on patients with a tendency to form keloids. There are multiple alternative approaches and techniques that attempt to eliminate or conceal these cervical scars, but they have been used almost exclusively in benign or congenital processes. Amid these aesthetic and/or minimally invasive cervical techniques, we highlight rhytidectomy/facelift, intraoral, endoscopic, and robotic approaches, among others. We present the novel application of a facelift approach for selective neck dissection in a young patient with a lateral tongue squamous cell carcinoma, with excellent cosmetic and oncologic results.

Zygomatic intraosseous haemangioma: reconstruction with an alloplastic prosthesis based on a 3-D model.

Intraosseous haemangioma are rare, benign tumours, and only rarely do they involve the facial bones. We present a singular case of zygomatic intraosseous haemangioma treated surgically and reconstructed with a methyl-methacrylate alloplastic prosthesis designed from a computed tomography (CT)-based 3D model. This is the first case described in the literature of a zygomatic reconstruction with a predesigned prosthesis. After 1 year of follow-up, aesthetical results are good, and the patient presents correct functional rehabilitation.

Endoscopic harvest of a temporalis flap for a maxillary reconstruction.

The use of a temporalis muscle flap for reconstruction of the maxilla is a common technique at the moment. One of the disadvantages of applying this technique is the anesthetic scar generated in the temporalis fossa and the depression of this area. We present a new method for endoscopically harvesting the muscle flap, through minimal incisions situated in the temporalis fossa and preauricular region. This endoscopic technique has not been described in the literature for a hemimaxillary reconstruction. We present the first case of a maxillary reconstruction with an endoscopically assisted temporalis muscle flap with excellent results.

Fracture of the anterior iliac crest following monocortical bone graft harvest in bisphosphonate-related mandibular pathological fracture: a case report.

The anterior iliac crest is the most common donor site for autologous nonvascularized bone because of the great amount of bone available and easy access. Documented donor-site complications include arterial, nerve, or urethral injury; herniation; chronic donor-site pain; sacroiliac joint instability; pelvic fractures; gait disturbances; hematoma; infection; peritoneal perforation; cosmetic defects; and hip subluxation. We present the case of a pathologic fracture of the right anterior iliac crest during the immediate postoperative period in a patient with a bisphosphonate-related osteochemonecrosis with pathological fracture of mandibular body. The patient was managed with nonoperative treatment.

Traumatic neuroma of the inferior alveolar nerve: a case report.

Traumatic neuromas are rare entities which characteristically arise subsequently to surgery and are usually accompanied by pain, typically neuralgic. We present an unusual case of an intraosseous traumatic neuroma of the inferior alveolar nerve following tooth extraction. A 56-year-old man consulted for paresthesias and hyperesthesia in the left mandibular region following extraction of the left mandibular third molar (#38). The panoramic radiograph revealed a radiolucent lesion in the inferior alveolar nerve canal, and CT demonstrated the existence of a mass within the canal, producing widening of the same. Nerve-sparing excisional biopsy was performed. Histopathology and immunohistochemistry were consistent with traumatic neuroma of the left inferior alveolar nerve. After 3 years of follow-up, the patient is asymptomatic and there are no signs of recurrence.

Oral primary angiosarcoma of the lower lip mucosa: report of a case in a 15-year-old boy.

BACKGROUND: Angiosarcomas are rare soft tissue malignant tumors with dismal prognosis. Head and neck involvement is uncommon (5%) and usually affects the scalp or facial skin. METHODS AND RESULTS: We present the case of an inferior lip mucosal low-grade angiosarcoma in a 15-year-old boy treated exclusively with surgery. One and a half years after treatment, the patient was free of signs of recurrence. Prompt and accurate diagnosis with adequate imaging modalities and multidisciplinary treatment are crucial for optimal management of these neoplasms. CONCLUSION: Lip mucosal involvement is exceptional with only a few cases described in the literature, all in patients older than 60 years To our knowledge, this is the youngest patient ever reported.