Paramagnetic contrast medium in high-level athletes with lower limb muscle injuries: can it make the return to sport safer reducing the recurrence rate?

PURPOSE: The aim is to investigate whether contrast medium can improve accuracy in the assessment of healing muscle injury in high-level professional athletes. MATERIALS AND METHODS: Our series is a retrospective study including the records of 22 players (mean age 28 ± 5 SD) with lower limbs muscle injuries type 3a (Mueller-Wohlfarth). All athletes received two MRIs: the day after the injury and before resuming heavy effort activities. Contrast medium uptake was measured in the second MRI by comparing the mean enhancement at the lesion site (ME) with that of the healthy contralateral muscle (HM). The result is a percentage referred to as muscular contrast index (MC index). The difference between the mean MC index value between athletes with and without re-injury was assessed with both the Mann-Whitney and the Kruskal-Wallis test. RESULTS: Twenty-nine muscle injuries matched the inclusion criteria. The mean MC index values, adjusted for the variable of time elapsed between the last contrast examination and return to the field, were significantly different in the two study groups (p < .001). CONCLUSION: The contrast medium in the follow-up of muscle injuries may be useful in determining the degree of scar stability in a healing injury. Injuries with a high MC index were found to be 'unstable', with a higher rate of recurrence than those with a low MC index. Resumption of competitive activity after achieving not only clinical resolution but also a satisfactory MC index value may increase the safety of return to the field and reduce the recurrence rate.

MRI evaluation of meniscal anatomy: which parameters reach the best inter-observer concordance?

PURPOSE: The aim of the study is to evaluate which MRI parameters achieve the best degree of inter-individual concordance in the description of meniscal fibrocartilage, regarding its morphology, signal and position. MATERIALS AND METHODS: Eighty-nine knee MRIs were included in the study, retrospectively re-evaluated by three radiologists who completed a binary report (normal/abnormal) describing the meniscus signal, position relative to the tibial plateau margin and morphology. The inter-individual concordance value was calculated using Cohen's test. RESULTS: We obtained different inter-individual concordance values according to the parameters considered. The concordance was poor in the description of the meniscal position relative to the tibial plateau margin (average k = 0.6); the result was comparable in the description of the meniscal morphology (average k = 0.56). The best results were obtained with the meniscal signal analysis (average k = 0.8). CONCLUSION: To the best of our knowledge, there are no studies in the literature assessing the concordance between multiple readers in the description of the parameters we studied. The results we obtained suggest that the most reliable parameter for describing meniscal fibrocartilage is its signal intensity, whereas morphology and position may lead to different interpretations that are not always unequivocal.

MR arthrography: correlation between anatomic intraarticular variants of the long head of the biceps tendon (long head biceps tendon) and superior labral anterior to posterior (SLAP) lesions.

BACKGROUND: The purpose of this work is to characterize the anatomy of the intraarticular portion of the long head of the biceps tendon (long head biceps tendon) using magnetic resonance (MR) arthrography by investigating whether anatomical variants may facilitate the onset of a supraequatorial lesion (superior labral anterior to posterior, SLAP). MATERIALS AND METHODS: In 482 shoulder MR arthrographies, we considered the anatomical variants of the intraarticular portion of the long head of the biceps tendon classified according to Dierickx's arthroscopic classification; lesions of supraequatorial structures were considered in the data analysis. For each anatomical variant, correlation with SLAP and the odd ratio were statistically evaluated, using Fisher's exact (or chi-squared) test and logistic regression analysis, respectively. RESULTS: In the mesotenon-type variant, the SLAP frequency was higher than expected [χ2 (df = 4) = 14.9, p = 0.005] with a higher risk of developing a type I SLAP (p = 0.0003). In the adherent-type variant, the type II SLAP frequency was higher than expected [χ2 (df = 3) = 18.1, p = 0.0004] with a higher risk of developing type II SLAP (p = 0.0001). Two cases of "split" (SPL) long head biceps tendon had III and type IV SLAP, respectively. These patients have a higher risk for type IV SLAP [odds ratio (OR) 19.562, 95% confidence interval (CI) 1.604-238.541, p = 0.001]. An increased risk of developing SLAP type II was calculated for male subjects (OR 3.479, 95% CI 1.013-11.951, p = 0.019). CONCLUSIONS: It is possible that adherence of the long head biceps tendon to the supraspinatus more often predisposes to a lesion of the superior glenoid labrum (SLAP), in view of the close relationships between the fibrocartilage and the bicipital anchor, probably related to the limited excursion of the intraarticular long head biceps tendon.

Nonsurgical removal of a massive calcification of the shoulder.

Calcific tendinopathy of the shoulder is a prevalent and painful condition marked by calcific deposits in the rotator cuff tendons or subacromial bursa, with an incidence of 2.7% to 20%, predominantly affecting individuals aged 30 to 50. Women are 1.5 times more likely to be affected than men. Deposits are frequently bilateral in 10%-20% of cases and most commonly found in the supraspinatus tendon. The pathogenesis remains unclear, with theories suggesting repetitive strain or ischemic degeneration leading to calcium deposition. The disease progresses through precalcific, calcific, and postcalcific phases, with symptoms ranging from mild pain to severe, disabling pain resistant to medication. Diagnosis primarily involves radiographs or CT scans, with ultrasound aiding in deposit staging. Conservative treatments include medication, physiotherapy, and subacromial corticosteroid injections. Novel nonsurgical treatments like ultrasound-guided needling (UGN) and extracorporeal shock wave therapy (ESWT) have shown promise. When conservative measures fail, surgical options achieve significant improvement. This case report details a 53-year-old woman with a 12 cm calcification treated successfully with UGN, demonstrating the efficacy of this minimally invasive technique for large deposits.

MR-arthrography in superior instability of the shoulder: correlation with arthroscopy.

PURPOSE: This study was undertaken to evaluate magnetic resonance (MR) arthrography in the detection and classification of lesions that may cause superior instability. MATERIALS AND METHODS: Forty-two consecutive patients with clinical signs of chronic superior instability of the shoulder underwent MR arthrography followed by arthroscopic surgery. For each patient we retrospectively reviewed the MR arthrography and surgical findings. RESULTS: We detected 31 superior labral anterior posterior (SLAP) lesions, all confirmed on arthroscopy with three cases of underestimation: in the detection of SLAP lesions, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MR arthrography were 100%; in the evaluation of the type of SLAP lesion, sensitivity was 100%, specificity was 78.5%, accuracy was 92.8%, PPV was 71.7% and NPV was 100%. All cases of capsular laxity (13/42) and biceps tendon lesions (3/42) were confirmed on arthroscopy with sensitivity, specificity, accuracy, PPV and NPV of 100%. Eleven cuff lesions were detected on MR arthrography, 10 of which confirmed at arthroscopy: sensitivity was 100%, specificity was 96.8%, accuracy was 97.6%, PPV was 90.9% and NPV was 100%. Associated lesions were found in 38/42 patients. CONCLUSIONS: Superior instability is frequently associated with different anatomical variants or pathological conditions, such as SLAP lesions. The role of MR arthrography is to describe the key features of lesions affecting the superior portion of the shoulder, including location, morphology, extent, and associated injuries and leanatomical variants and to correlate these features with clinical symptoms.

Case report of a tibial fracture in a patient suffering from gout: An atypical site, the importance of differential diagnosis.

We present the case of a 60-year-old man with a history of severe tophaceous gout with polyarticular involvement who came to the emergency room due to direct trauma to the right forearm and knee. The knee X-ray and CT scan showed a lateral tibial plateau fracture characterized by the presence of a lytic bone lesion. The presence of a solid neoplasm was ruled out and a CT-guided biopsy was performed. Histological evaluation revealed findings typical for an advanced intraosseous gout. As there was no significant risk of progression of the lytic lesion, the fracture site was treated conservatively. This case is unique in the literature in terms of location and should be considered as an atypical site of intraosseous gout. Proper differentiation of a pathological fracture on an intraosseous gout location from a neoplastic lesion is essential to choose the correct therapy.

The role of intra-articular hyaluronan (Sinovial) in the treatment of osteoarthritis.

Osteoarthritis (OA) leads to significant pain and disability. For pain relief, a tailored approach using non-pharmacological and pharmacological therapies is recommended. If adequate symptom relief is not achieved with acetaminophen, other pharmacological options include non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, intra-articular corticosteroids and intra-articular hyaluronic acid (HA) viscosupplementation. Most of these therapies generally do not improve functional ability or quality of life or are associated with tolerability concerns. In OA patients, concentration and molecular weight (MW) of HA are reduced, diminishing elastoviscosity of the synovial fluid, joint lubrication and shock absorbancy, and possibly anti-inflammatory, analgesic and chondroprotective effects. In knee OA, viscosupplementation with 3-5 weekly intra-articular HA injections diminishes pain and improves disability, generally within 1 week and for up to 3-6 months and is well tolerated. HAs have comparable efficacy as NSAIDs, with less gastrointestinal adverse events, and compared with intra-articular corticosteroids, benefits last generally longer. High MW hylans provide comparable benefits versus HA, albeit with an increased risk of immunogenic adverse events. In mild-to-moderate hip OA, intra-articular injection of HA moderately improved pain and function, generally for up to 3 months with no serious adverse events. Efficacy in other joints is being evaluated. Viscosupplementation with intra-articular Sinovial(®) (other trade names: Yaral(®), Intragel(®)) injections (an HA of low-medium MW) relieves pain and improves function in OA of the knee, and other joints including the carpometacarpal joint of the thumb and the shoulder. HA viscosupplementation, including use of Sinovial(®), is a valuable treatment approach for OA patients, if other therapies are contraindicated or have failed.

Matrix-induced autologous chondrocyte implantation of the knee: mid-term and long-term follow-up by MR arthrography.

OBJECTIVE: To define magnetic resonance (MR) arthrography imaging findings of matrix-induced autologous chondrocyte implantation (MACI) grafts of the knee in order to describe implant behaviour and to compare findings with validated clinical scores 30 and 60 months after MACI implant. MATERIALS AND METHODS: Thirteen patients were recruited (10 male, 3 female) with a total number of 15 chondral lesions. Each patient underwent an MACI procedure and MR arthrography 30 and 60 months after surgery. MR arthrography was performed using a dedicated coil with a 1.5-Tesla unit. The status of the chondral implant was evaluated with the modified MOCART scoring scale. The lining of the implant, the integration to the border zone, the surface and structure of the repaired tissue were assessed, and the presence of bone marrow oedema and effusion was evaluated. For clinical assessment, the Cincinnati score was used. RESULTS: At 60 months, the abnormality showed worsening in 1 out of 15 cases. Integration showed improvement in 3 out of 15 cases, and worsening in 3 out of 15 cases. Two surfaces of the implant showed further deterioration at 60 months, and 1 afflicted implant fully recovered after the same time interval. Implant contrast enhancement at 30 months was seen in 2 out of 15 cases, 1 of which recovered at 60 months. According to the MOCART score, 4 cases were rated 68.4 out of 75 at 30 months and 65 out of 75 at 60 months. The mean clinical score decreased from 8.6 out of 10 at 30 months to 8.1 out of 10 at 60 months. CONCLUSION: Magnetic resonance arthrography improved the evaluation of implants and facilitated the characterisation of MACI integration with contiguous tissues. The follow-up showed significant changes in MACI, even at 60 months, allowing for useful long-term MR evaluations.

Analysis of achilles tendon vascularity with second-generation contrast-enhanced ultrasound.

PURPOSE: To compare morphological, power Doppler, and contrast-enhanced ultrasound (CEUS) features of the Achilles tendon between asymptomatic athletes and athletes who had undergone surgical repair of a previous rupture. METHODS: Twenty-four athletes were divided in two groups (A and B). Group A included 14 patients with a median age of 32 years (range 27 to 47 years) who had undergone surgical repair for unilateral Achilles tendon rupture. Group B (control group) included 10 subjects with a median age of 34 years (range 27 to 40 years) with no previous or present history of tendinopathy. All patients were evaluated with ultrasound, power Doppler, and CEUS with second-generation contrast agent. We studied the uninjured Achilles tendon in athletes of group A and either the left or the right Achilles tendon of the athletes in group B. RESULTS: CEUS showed a significantly greater ability to detect a greater number of vascular spots within the uninjured tendon of group A compared to group B (<0.05). CONCLUSIONS: In athletes who had suffered a tear of an Achilles tendon, CEUS detected small vessels that were not identified by power Doppler ultrasound in the uninjured contralateral Achilles tendon. CEUS is useful to evaluate vascularity not detected by other imaging techniques. Vascularity in the uninjured tendon seems to be increased in patients who had a previous rupture.

Ultrasound-guided removal of foreign bodies: personal experience.

Foreign bodies (FBs) retained in the soft tissues are a common reason for medical consultation, and usually consist of wooden or metal splinters or glass shards. Failure to remove foreign bodies is likely to give rise to acute or late complications, such as allergies, inflammation or infection, that may be severe. The surgical removal of an FB is invasive, costly and technically challenging. The procedure may fail in some cases and carries the risk of complications. Our study describes a technique for the ultrasound-guided removal of an FB, devised from our experience, and demonstrates its advantages over the standard surgical procedure. Sixty-two patients (43 males and 19 females aged from 9 to 65 years, median age 31 years) presented at our institution between October 2005 and June 2008 with suspected foreign bodies retained in the soft tissues of various body districts. Radiographic and/or ultrasound diagnosis was established by a radiologist expert in musculoskeletal sonography. The same radiologist helped by a nurse subsequently undertook the ultrasound-guided removal in the outpatient's clinic according to the technique described in the paper. ATL 5000 and PHILIPS iu22 ultrasound systems were used with high-frequency linear-array probes, sterile material, local anaesthetic (lidocaine 2%), scapels and surgical forceps. Antibiotic prophylaxis with amoxicillin and clavulanic acid were prescribed to all patients for 7 days after the procedure. Ninety-five FBs (39 glass, 35 metal, 17 vegetable, 2 plastic, 2 stone) were successfully removed under ultrasound guidance in all patients and the procedure took between 15 and 30 min. No complications arose either during or after the procedure. Seventy-five skin incisions were made and the wounds closed with Steri-Strips in 73/75 cases, whereas skin sutures were used in 2/75 cases. No complications arose either during or after the procedure. Ultrasound-guided removal of an FB retained in the soft tissues is a good alternative to surgery as is its relatively straightforward, inexpensive, repeatable and carries a low risk of complications. In addition, failure to remove an FB does not preclude traditional surgical removal. The advantages of this real-time procedure and the use of small instruments minimize bleeding time and avoid injury to surrounding structures. Patient compliance is enhanced by the fact that the procedure has little or no aesthetic impact. These encouraging results suggest ultrasound-guided removal as a first-choice procedure for the extraction of foreign bodies.

Ultrasound-guided injection of a corticosteroid and hyaluronic acid: a potential new approach to the treatment of trigger finger.

BACKGROUND AND OBJECTIVES: Stenosing tenosynovitis (trigger finger) is one of the most common causes of pain and disability in the hand, which may often require treatment with anti-inflammatory drugs, corticosteroid injection, or open surgery. However, there is still large room for improvement in the treatment of this condition by corticosteroid injection. The mechanical, visco-elastic, and antinociceptive properties of hyaluronic acid may potentially support the use of this molecule in association with corticosteroids for the treatment of trigger finger. This study examines the feasibility and safety of ultrasound-guided injection of a corticosteroid and hyaluronic acid compared, for the first time, with open surgery for the treatment of trigger finger. METHODS: This was a monocentric, open-label, randomized study. Consecutive patients aged between 35 and 70 years with ultrasound-confirmed diagnosis of trigger finger were included. Patients were randomly assigned to either ultrasound-guided injection of methylprednisolone acetate 40 mg/mL with 0.8 mL lidocaine into the flexor sheath plus injection of 1 mL hyaluronic acid 0.8% 10 days later (n = 15; group A), or to open surgical release of the first annular pulley (n = 15; group B). Clinical assessment of the digital articular chain was conducted prior to treatment and after 6 weeks, and 3, 6, and 12 months. The duration of abstention from work and/or sports activity, and any treatment complications or additional treatment requirements (e.g. physiotherapy, compression, medication) were also recorded. RESULTS: Fourteen patients (93.3%) in group A had complete symptom resolution at 6 months, which persisted for 12 months in 11 patients (73.3%), while three patients experienced recurrences and one experienced no symptom improvements. No patients in group A reported major or minor complications during or after corticosteroid injection, or required a compression bandage. All 15 patients in group B achieved complete resolution of articular impairment by 3 weeks after surgery, but ten patients were assigned to physiotherapy and local and/or oral analgesics for complete resolution of symptoms, which was approximately 30-40 days postsurgery. The mean duration of abstention from work and/or sport was 2-3 days in group A and 26 days in group B. CONCLUSIONS: Although the limited sample size did not allow any statistical comparison between treatment groups, and therefore all the findings should be regarded as preliminary, the results of this explorative study suggest that ultrasound-guided injection of a corticosteroid and hyaluronic acid could be a safe and feasible approach for the treatment of trigger finger. It is also associated with a shorter recovery time than open surgery, which leads to a reduced abstention from sports and, in particular, work activities, and therefore may have some pharmacoeconomic implications, which may be further explored. In light of the promising results obtained in this investigation, further studies comparing ultrasound-guided injection of corticosteroid plus hyaluronic acid with corticosteroid alone are recommended in order to clarify the actual benefits attributable to hyaluronic acid.

MR Arthrography: a proposal for solution optimization with lidocaine. An in vitro experience.

PURPOSE: Pain on capsule distension in painful joints may affect feasibility of the MR Arthrography. We tried to overcome this limitation by adding a local anesthetic (lidocaine) to the paramagnetic contrast agent solution. We aimed at: a) investigating which contrast agent dilution provides the best signal-to-noise ratio in the SE T1 sequences; b) evaluating the effects of lidocaine on the signal intensity and on the viscosity of the solutions; assessing the viscosity of solutions containing iodinated contrast agent. MATERIALS AND METHODS: The paramagnetic contrast agent was diluted with saline and lidocaine at various concentrations. Signal intensity was measured with a 1.5 Tesla superconductive MR unit with a dedicated head coil; we used T1-weighted spin-echo sequence. The viscosity coefficient of the solutions was analyzed and compared with that of solutions containing iodinated contrast agents (but not lidocaine). RESULTS: Signal intensity is also unaffected by variations in the concentration of lidocaine, which does not interfere with the biphasic behavior of Gadolinium. Viscosity is scarcely affected by changes in lidocaine concentration when the paramagnetic contrast agent concentration is not changed. CONCLUSIONS: The optimal signal-to-noise ratio in T1-weighted sequences is provided by 0.4%, contrast agent dilution but contrast agent-saline solutions, with(out) lidocaine, cannot be considered steady and signal intensity values change over time. The addition of lidocaine does not significantly influence the signal-to-noise ratio and the viscosity of the solutions. The low viscosity of the paramagnetic contrast agent appears to favor quicker spread of the solution, even in tiny defects; thanks to its anesthetic effect, lidocaine could facilitates execution of the examination in painful joints without affecting the diagnostic result.