Percutaneous cementoplasty of periprosthetic loosening: can interventional radiologists offer an alternative to revision surgery?

OBJECTIVE: To evaluate feasibility and validate both safety and efficiency of radiological percutaneous periprosthetic bone cementoplasty (RPPBC) performed under local anesthesia as an alternative minimally invasive treatment of aseptic implant loosening. METHODS: In this case series, seven patients (mean age 81 years, range 73 to 89 years, 2 men and 5 women) were enrolled between February 2011 and January 2020 with confirmed aseptic loosening of orthopedic implants. One patient presented with tibial component loosening of an unicompartmental knee arthroplasty, one with glenoid component loosening from a reverse shoulder arthroplasty, one femoral gamma nail, and four presented with pedicle screw loosening after staged posterior lumbar interbody fusion. All patients underwent clinical, biochemical, and imaging assessments to confirm the diagnosis of aseptic loosening. All benefited from RPPBC under dual CT and fluoroscopic guidance. All procedures were performed under local anesthesia by an experienced radiologist. Preprocedural, immediate and 6-month post-cementoplasty pain levels on a visual analogue scale (VAS), and functional outcomes were evaluated. Immediate and 6-month postprocedural CTs were performed to evaluate the treated region. RESULTS: All RPPBC were well tolerated by patients throughout the procedure. None of the patients suffered from local or systemic infection post-RPPBC, or periprosthetic fractures. No recurrent implant loosening was observed. Six patients were pain free at 6 months. All patients expressed functional improvements during validated outcome score evaluations. CONCLUSION: RPPBC appears to be an efficient and reliable treatment strategy for aseptic loosening of orthopedic implants in elderly patients deemed unfit for revision surgery. KEY POINTS: • Radiological percutaneous periprosthetic bone cementoplasty offers immediate and long-lasting pain relief in elderly frail patients, or those deemed unfit for revision surgery despite presenting with symptomatic aseptic loosening of orthopedic implants. • Radiological percutaneous periprosthetic bone cementoplasty brings quick and long-lasting improvements in clinical functional outcomes and offer effective pain reduction, thereby improving the overall quality of life. • Radiological percutaneous periprosthetic bone cementoplasty is a safe, quick, reliable, and well-tolerated minimally invasive procedure which can be easily performed under simple locoregional anesthesia and requires short-term hospital stay.

Five simultaneous artificial intelligence data challenges on ultrasound, CT, and MRI.

PURPOSE: The goal of this data challenge was to create a structured dynamic with the following objectives: (1) teach radiologists the new rules of General Data Protection Regulation (GDPR), while building a large multicentric prospective database of ultrasound, computed tomography (CT) and MRI patient images; (2) build a network including radiologists, researchers, start-ups, large companies, and students from engineering schools, and; (3) provide all French stakeholders working together during 5 data challenges with a secured framework, offering a realistic picture of the benefits and concerns in October 2018. MATERIALS AND METHODS: Relevant clinical questions were chosen by the Société Francaise de Radiologie. The challenge was designed to respect all French ethical and data protection constraints. Multidisciplinary teams with at least one radiologist, one engineering student, and a company and/or research lab were gathered using different networks, and clinical databases were created accordingly. RESULTS: Five challenges were launched: detection of meniscal tears on MRI, segmentation of renal cortex on CT, detection and characterization of liver lesions on ultrasound, detection of breast lesions on MRI, and characterization of thyroid cartilage lesions on CT. A total of 5,170 images within 4 months were provided for the challenge by 46 radiology services. Twenty-six multidisciplinary teams with 181 contestants worked for one month on the challenges. Three challenges, meniscal tears, renal cortex, and liver lesions, resulted in an accuracy>90%. The fourth challenge (breast) reached 82% and the lastone (thyroid) 70%. CONCLUSION: Theses five challenges were able to gather a large community of radiologists, engineers, researchers, and companies in a very short period of time. The accurate results of three of the five modalities suggest that artificial intelligence is a promising tool in these radiology modalities.

The G-spot: an observational MRI pilot study.

OBJECTIVES: To identify a G-spot complex (GSC) in vivo in MRI examinations at 1.5 Tesla field strength. DESIGN: Observational study. SETTING: Single centre. POPULATION: Twenty-one consecutive patients (January-March 2014). METHODS: Imaging analysis of routine imaging protocols for usual medical indications with and without concomitant opacification of the vaginal cavity with inert ultrasound gel. The gel distends the otherwise collapsed vaginal walls, allowing for an improved discrimination of anatomic features. The macroscopic and histological results recently derived from the dissections of fresh cadavers by Ostrzenski et al. were translated into imaging characteristics to be expected in the respective MRI sequences (e.g. T1- and T2-weighted) in search of an in vivo correlate of the GSC. Age, menopause status, medical indication and diagnosis were co-variables. MAIN OUTCOME MEASURES: To analyse primarily whether MRI imaging is able to depict a distinct morphological entity in vivo matching the GSC, based on anatomical descriptions published recently. The elaboration of an appropriate MRI-imaging protocol was a secondary aim. RESULTS: A total of 21 studies were obtained. A GSC was identified within the anterior vaginal wall in 13/21 patients (62%). In all, 10/21 (48%) had vaginal gel opacification. We identified a GSC in 10/10 patients (100%) with opacification in all three planes of the T2 images. This was only true for 3/11 cases (27%) without opacification. CONCLUSIONS: There is evidence for an in vivo morphological correlate to the postmortem anatomical findings of a GSC described by Ostrzenski et al.; its visibility in MRI imaging can be significantly improved with vaginal opacification by ultrasound gel. TWEETABLE ABSTRACT: Identification of G-spot by MRI with vaginal gel-opacification in 13/21 patients.

Interest of including trauma photography in the picture archiving and communication system of a teaching hospital.

Digital imaging is a daily practice in traumatology. Such photographs should remain confidential. However, there is a need for objectivity concerning the circumstances and clinical follow-up for trauma patients. This paper describes how to conserve these photographs within the picture archiving and communication system (PACS) safely as regards identity and confidentiality. A computer converts the photographs into DICOM files. The DICOM image is associated to a reconciliation layer, validated by the physician in charge, and then included in the hospital PACS. This improves transmission from one medical team to another, both initially and after the accident if an expert medical opinion is required. The literature has demonstrated the value of photographs in modern medicine, but the technical and legal challenges are many. They enhance the computerized medical records. Identification, confidentiality and integration in the PACS are obstacles that we have now overcome.

Bisphosphonate therapy for unresectable symptomatic benign bone tumors: a long-term prospective study of tolerance and efficacy.

OBJECTIVES: To evaluate the long-term tolerance of bisphosphonates proposed as an alternative therapeutic option for symptomatic unresectable benign bone tumors and to evaluate the long-term efficacy of this treatment. METHODS: From March 2007 to March 2011, patients with unresectable symptomatic benign bone tumors were consecutively included in this institutional review board-approved study and treated with bisphosphonates. Prospectively long-term follow-up is reported. The study endpoints were to describe the long-term tolerance, the clinical evolution of pain for each patient and the radiological success defined as a complete disappearance of inflammation and ossification of the bone lesion. All complications and side effects were recorded. RESULTS: Eight patients (mean age 16 years; range 7-42) with various tumor subtypes were included: aneurysmal bone cysts (N=5), Langerhans cell histiocytosis (N=1), osteoblastoma (N=1), and a giant cell tumor (N=1). Tumors were located in cervical (N=4) or thoracic (N=1) vertebrae, femoral shaft (N=1), acetabulum (N=1) and sacrum (N=1). Mean number of bisphosphonate cycles was 3 (range: 1-6) over a median period of 10 months. The median clinical and imaging follow-up period was 21 months (6 to 63 months). No severe complications due to treatment or lesion recurrence were reported. Pain disappeared within 6 weeks of the first cycle for all but one patient. Ossification of the bone lesion was observed for all patients but one, complete for two and partial for the five others. CONCLUSIONS: Bisphosphonates appear to be an effective option without adverse effects for the non-operative management of symptomatic benign bone tumors.

Radiologically guided percutaneous cryotherapy for soft tissue tumours: A promising treatment.

Studies of percutaneous cryotherapy in the treatment of benign or malignant soft tissue tumours are rare and mainly involve small populations. Nevertheless, results show cryotherapy's potential in terms of local control of tumours, analgesic efficacy, reduced intra- and postoperative complications, and reduction in the length of convalescence after the procedure. The objective of this update is to set out the short-term prospects for this technique in the treatment of soft tissue tumours, so that it may be more widely offered in these indications.

Comparison between percutaneous and traditional fixation of lumbar spine fracture: intraoperative radiation exposure levels and outcomes.

OBJECTIVE: To compare radiation exposure doses and clinical and radiological outcomes between percutaneous pedicular screwing (closed reduction internal fixation [CRIF]) and classical open reduction internal fixation (ORIF) in lumbar spine fracture without neurologic deficit. MATERIALS AND METHODS: Sixty patients (mean age, 42.5 years) were divided into two treatment groups: (Percutaneous) CRIF versus (traditional) ORIF. Screw position and anatomic vertebral reconstruction were checked on routine control X-ray and postoperative CT scan. Study parameters comprised: surgery time, radiation exposure time, radiation dose level for X-ray (DAP) and for CT (DLP),blood loss, length of hospital stay and postoperative pain (VAS). RESULTS: At a mean 25.5 months' follow-up,there were no significant inter-group differences on the epidemiological parameters: age, gender, fracture level, fracture type on the Magerl classification, preoperative local vertebral kyphosis angle, or fracture-to-surgery interval. Effective radiation dose was 3-fold higher in CRIF than in ORIF, but 6-fold lower than for the postoperative CT scan. Postoperative pain on VAS was significantly lower after CRIF, allowing earlier gait resumption and return to work and daily activity. There were no significant differences in length of hospital stay, patient satisfaction, screw malpositioning or postoperative or end-of-follow-up kyphosis angle. CONCLUSION: Percutaneous surgery provided clinical and radiological outcomes strictly comparable to those of open surgery, but with a higher effective radiation exposure dose, including for the medical team and especially for the surgeon. This higher exposure dose, however, is to be relativized by comparison to that of the postoperative CT scan, which involved a much higher exposure dose for the patient. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Percutaneous cementoplasty for the treatment of extraspinal painful bone lesion, a prospective study.

PURPOSE: The current gold standard treatment of localized painful bone lesion is radiotherapy but this technique has limitations. Our study aims to demonstrate that cementoplasty is an efficient alternative for these palliatives indications when lesions involve extraspinal bones. We prospectively followed 20 patients who received a percutaneous cementoplasty on painful lytic bone lesions between May 2008 and May 2010. MATERIALS: Seventeen patients also had difficulty walking in relation to the pain experienced. The clinical indication for treatment was severe pain (≥4 on the numeric scale) due to bone lesion on CT or MRI. All procedures (except one) were performed under local anesthesia. RESULTS: Feasibility was 100% without immediate complications. The patients experienced a significant and rapid decrease of their pain (4.1 points, P<000.1) and this effect was sustained over the long term (7.75 months of follow-up on average). Sixty-four percent of patients treated on the lower limbs and pelvis improved mobility. CONCLUSION: In our experience, percutaneous cementoplasty may be a safe and effective palliative treatment for localized painful lytic lesion. Combining CT and fluoroscopic guidance seems to be the safer option because of extravertebral localization. Smart fill of the bone and careful selection of patient determine the effectiveness of the procedure. Diffuse painful lesions and long bone diaphysis should not be good indications.

Approaches in injections for radicular pain: the transforaminal, epidural and transfacet approaches.

Spinal injections must be carried out adhering to very strict conditions. However, these procedures have almost come to be seen as everyday and may be practised under quite questionable conditions. The recent reports of new and extremely serious neurological complications have changed the attitudes of those making referrals as well as the attitudes of the interventional radiologists carrying out these procedures. The range of indications for transforaminal injections has shrunk in favour of epidural injections. Where the transforaminal approach is still used, the needle must be positioned extremely accurately. A prior radioopaque contrast medium injection is essential from a safety perspective. The transforaminal epidural injection via the transfacet approach looks to be a promising alternative that is strictly avascular.

Imaging of intervertebral disc prostheses.

Disc arthroplasty is the replacement of a painful pathological intervertebral disc by a prosthesis, which, unlike spinal fixation, has the advantage of retaining vertebral mobility in the segment concerned. The success of the procedure is dictated by the indication. The radiologist must look for radiographic arguments indicating or contraindicating fitting an implant, and particularly for the presence of facet arthritis which will prompt the surgeon to choose an arthrodesis. Moreover, radiological information plays a major part in preparing for a surgical procedure, as far as access to the disc via the anterior approach is concerned and assessment by CT angiography of the risk of vascular complications. After insertion, radiological monitoring using dynamic X-ray images checks that the implant is correctly positioned and that mobility is restored. In the long term, it can detect complications related to the prosthesis and premature wear to other points of support such as adjacent discs and the facet joints.

[Discoscanner: indications, technique, tips and tricks, interpretation]. / Discoscanner: indications, technique, trucs et astuces, interprétation.

Discography test associated with the scanner (discoscanner) is an exam that has been a renewed interest in recent few years. Thanks to the emergence of new interventions such as disc prosthesis, the procedures require confirmation of the disc level to deal with and the origin of discogenic symptoms. The aim of this paper is to describe the techniques, challenges and tips as well as the interpretation of functional and morphological examination.

[Labral pathology and impingement]. / Pathologie labrale et conflits de hanche.

The acetabular labrum, a fibrocartilaginous structure essential to the proper functioning of the hip joint, may be damaged from a variety of conditions including femoroacetabular impingement. FAI is defined by abnormal contact between the femur and acetabulum and is characterized by an underlying morphological abnormality of the femur (dysplastic bump at the head/neck junction, Cam effect), acetabulum (excessive coverage, Pincer effect), or both. The abnormal morphology is suspected on plain films and additional evaluation with either CT or MR arthrography is then performed. The role of the radiologist is to describe the imaging findings while allowing the clinician to make the diagnosis based on clinical symptoms (groin pain, reduced internal rotation). Comprehensive evaluation of the underlying structural abnormalities and associated lesions is important to optimize surgical management with the goal of reducing painful symptoms, improve range of motion and prevent early hip joint degeneration.

[Posterior percutaneous arthrodesis under CT guidance after surgical anterior arthrodesis: a new technique]. / Arthrodèse percutanée postérieure sous guidage scanner en complément de l'arthrodèse antérieure chirurgicale: une nouvelle technique.

Transfacet screws may be useful for stabilizing segments reconstructed with bone graft or cages, the role of supplementary posterior fixation, particularly minimally invasive techniques such as transfacetar percutaneous screws is relevant. To benefit from a mechanical fixation after anterior arthrodesis without the inconveniences of the open classical posterior surgical intervention, we have developed a new procedure performed under local anesthesia and CT guidance and based on the intra-articular application of screws. This study was designed to demonstrate the feasibility of using a CT-scan to perform posterior arthrodesis of the spine under local anesthesia.

[Vertebroplasty and kyphoplasty under dual guidance (CT and fluoroscopy): radiation dose to radiologist. A comparative study]. / Étude dosimétrique comparative de la vertébroplastie et de la kyphoplastie sous double guidage: scanner et fluoroscopique.

OBJECTIVES: The goals of this study is to evaluate and compare the irradiation received by the practitioner when performing percutaneous vertebroplasty or kyphoplasty guided by CT and fluoroscopy, for precise anatomical sites. METHODS: For each intervention, radiothermoluminescent dosimeters were carefully positioned on both orbitals, both hands, and both ankles of the practitioner. RESULTS: Twenty-four vertebroplasties were performed in 18 patients and nine kyphoplasties on seven patients. The anatomical site that is most exposed to radiation is the right hand. The two other sites subjected to irradiation are the left hand and the left orbital. This study demonstrates a significant correlation between the irradiation dose and fluoroscopy duration, reflecting both the quantity of primary-beam radiation and backscattered radiation. CONCLUSION: The radiation dose to radiologist is more important for kyphoplasty procedures than vertebroplasty.

[Extension reserve of the hip in relation to the spine: Comparative study of two radiographic methods]. / Mesure de la réserve d'extension de la hanche en relation avec le rachis. Etude comparative de deux méthodes radiologiques.

SUMMARY: Free-hip movement is necessary for good spinal function. Limitation generally affects extension. The range of hip extension from the standing position can be considered as the hip's "extension reserve". The amplitude of this reserve must be known because any deficit requires a pathological solicitation of the vertebral column. Measurement of the extension reserve of the hip is useful for analyzing spinal disease and for preoperative planning. Physical examination can measure extension, but cannot differentiate movement produced by the hip from that originating in the spine. We have been unable to locate any radiographic method in the literature. The purpose of this study was to evaluate radiographic measurements and to propose a novel method. The study was conducted with 37 patients with spinal disease. Two radiographic methods were compared. Four lateral views, including the lumbar spine, the pelvis and the femur were obtained in each patient: neutral position, retroversion of the pelvis and extension of each hip in lunge position. The X-rays were digitalized for computer processing. The extension reserve of the hip was calculated for each radiographic method. Extension reserve was defined as the difference in the pelvis-femoral angle between the neutral position and extension. There was a positive correlation between the two methods (p<0.0006; p<0.0009). Mean extension using the pelvis retroversion method was 1.8 degrees +/-6.77; with the hip-extension method, it was hip I (side with the superior value): 15.9 degrees +/-6.57; hip II 10.0 degrees +/-7.89. The pelvis-retroversion method gave a lower measurement compared with the lunge position method (p<0.0001). For 13 of 37 subjects (35%), this method gave negative values, that is, failure of the measurement method. The method of hip extension in lunge position was superior to the pelvis-retroversion method, which gave lower measurements that were often incoherent and unable to provide specific information for each hip. The method using the lunge position for hip extension appears to be preferable. We are currently conducting a clinical trial to include extension reserve in the analysis of sagittal balance and for determining curvature corrections. We propose a mathematical formula using extension reserve for determining sagittal correction. Radiographic determination of extension reserve of the hip joint is of major importance for assessing spinal disease in addition to its contribution to the analysis of hip and pelvic disease. The methods presented here enable radiographic measurement of the extension reserve of the hip.

A comparison between distal and proximal port device insertion in head and neck cancer.

AIM: To compare technical feasibility and complications of radiologically arm port device implantation using arm venography exclusively (API-Group B) with chest port placement using cephalic vein cutdown (CVC-Group A), in advanced consecutive head and neck cancer patients (HNP). METHODS: Port device placement was attempted in 225 consecutive HNP. Decision for inclusion in Group A or B was made first by the availability of the surgeon/radiologist to perform the procedure, second by contraindications of each technique. Patient transfer from one group to the other was recorded as well as technical feasibility, complications and device specific duration in this retrospective study. RESULTS: Technical success was statistically higher in Arm Port Group (99.1%) compared to Chest Port Group (75.2%). Device specific duration rate of the whole population was 53% (95%CI) [0.47-0.60] at 6 months, 44.1% (95%CI) [24.4-37.8] at 12 months and 8% (95%CI) [4.4-14.5] at 24 months. Median follow-up was 5.55 months (range: 0.032-9.6] in Group A versus 5.90 months [range: 0.06-27.6] (p=ns) in Group B. Complication rate was 15.9% in Group A versus 8.9% in Group B corresponding to a complication rate per patient-implantation-days of 0.66/1000 patient-days (A) versus 0.42/1000 patient-days (B). Premature port device explantation rate was 4.4% (A) versus 5.4% (B). Axillary and subclavian venous thrombosis was the main complication and occurred in 12 Group A patients and three Group B patients. Venous thrombosis rate was 0.37/1000 patient-days (A) and 0.13/1000 patient-days (B) (p=0.03). CONCLUSIONS: A few data exist about device insertion in HNP in whom venous cervical access is contraindicated. This comparative study demonstrates that both implantation techniques are safe and effective. The higher technical success rate with 0% heavy sedation, the lower venous thrombosis rate in the API group, and the 5.3% (A-B) patient transfer rate argue in favour of arm port placement in HNP. Indications for API include patients with an ipsilateral major pectoralis-myocutaneous flap, with radiodermatitis, tumour recurrence in the neck and upper chest, or with respiratory impairment.

[Percutaneous vertebroplasty in symptomatic osteoporotic vertebral compression fractures: review of 50 patients]. / Résultats de la vertébroplastie percutanée dans le traitement des fractures vertébrales ostéoporotiques hyperalgiques (50 cas).

PURPOSE: Evaluation of percutaneous vertebroplasty (PVP) in symptomatic osteoporotic vertebral compression fractures after failure of conservative management. MATERIALS AND METHODS: Retrospective study of cases performed between 2002 and 2005 in a single institution. Outcome was measured using Huskisson's visual analogue scale. RESULTS: A total of 77 vertebrae in 50 patients were treated. Mean follow-up was 12.9 months (1-36 months). Significant symptomatic improvement (p<0.001) was noted with pre PVP pain score of 7.4 (+/-0.99), 24 hour and 1 month post PVP score of 2.31 (+/-2.65), 6 month post PVP score of 2.4 (+/-2.7) and 18 month post PVP score of 2.91 (+/-2.91). Seven patients presented with a new symptomatic vertebral compression fracture, with 5 cases adjacent to the treated level. CONCLUSION: Percutaneous vertebroplasty is reliable and effective in the treatment of symptomatic osteoporotic vertebral compression fractures.

Percutaneous nucleotomy: preliminary communication on a decompression probe (Dekompressor) in percutaneous discectomy. Ten case reports.

For the past years, new therapeutic options have been proposed secondary to the progress in the interventional imaging. The purpose of this article is to report a preliminary study on the use of the 1.5 mm "Dekompressor probe" (Stryker, Kalamazoo, MI, USA) in the percutaneous discectomy by decompression. We have conducted, from September 2003 to March 2004, a retrospective review on 10 patients (mean age of 49.8), chosen at random, presenting a nonextruded herniated disc resisting all medical treatments. The procedure is CT guided or performed under fluorosocopy, a discography is performed by introducing the probe at the level of the protruded disc. After local anesthesia, an incision of a few millimeters is performed, allowing the introduction of a coxial trocar to the level of the disc. The decompression probe is then introduced. No technical failure occurred. The results in our series show, in eight patients, a satisfactory result with a decrease of the initial VAS of more than 70% and a complete elimination of the medical therapy. Our preliminary results are encouraging but should also be confirmed by a multicentric based on a large series, and the criteria of inclusion or exclusion must be strictly respected to obtain satisfactory clinical results.