Ultrasound in degenerative cystic meniscal disease of the knee.

Ultrasonography of the knee joint using small-parts probes was performed on 27 patients with clinical findings suggestive of meniscal cystic degeneration. Surgical or arthroscopic confirmation of sonographic findings was obtained in all cases. Sonography delineated the shape and structure of the meniscal profile and any degenerative changes. In the initial stage (6/27 patients, 22%), minor structural irregularities could be observed. Small, round, transonic cysts were found in 8 patients (30%); these lay mainly within the meniscus and were movable during stress flexion of the leg. In more advanced cases (8/27, 30%), larger cysts sometimes protruded on the skin surface. In 3 patients (12%), the soft tissue swelling was associated with a normal sonographic aspect of the menisci, but sonography could demonstrate an effusion of extra-articular origin. Ultrasound is a simple and effective method for the assessment of degenerative cysts of the menisci. It allows a reliable differential diagnosis between meniscal cysts and other causes of soft tissue swelling, and it is well suited for monitoring the course of the disease.

Sonographic appearances of hemangiomas of skeletal muscle.

The sonographic findings observed in seven patients with muscular hemangiomas were reviewed. An intramuscular mass (size range of 1.5 to 10 cm) was seen in all cases. Five lesions had oval shapes and smooth margins; two had irregular shapes and borders that were not clearly defined. Hyperechoic structure was noted in three lesions; two were hypoechoic; two had heterogeneous echo patterns. Three other muscular hemangiomas (two hyperechoic, one heterogeneous) are reported in the sonographic literature. Therefore, from the literature and from our own observations of hemangiomas, a hyperechogenic mass is the most common sonographic presentation of these tumors. However, there is not a specific sonographic appearance to muscular hemangiomas and other diagnostic tests are needed to establish the diagnosis.

Ultrasonic diagnosis of Osgood-Schlatter and Sinding-Larsen-Johansson diseases of the knee.

High resolution ultrasonography of the knee was performed on 82 young patients with clinically suspected Osgood-Schlatter disease and on 30 normal subjects; in 45 pathological cases (55%) comparative X-ray films were taken. The ultrasound pictures were equally or more effective than X-ray images in 45/45 cases; their value was particularly marked for soft tissue study. The typical sonographic changes of the ossification center, of the cartilage, and of the surrounding soft tissues are described and classified, both for Osgood-Schlatter and for Sinding-Larsen-Johansson diseases. These signs are based mainly upon cartilage swelling and edema, fragmentation of the ossification center, thickening of the patellar tendon, and bursitis of the infra-patellar bursa. Ultrasonography is proposed as a simple and reliable method for the diagnosis of knee joint osteochondrosis. The ultrasound picture is also suitable for periodical follow-up the course of the disease.

Dynamic ultrasonography of capsulo-ligamentous knee joint traumas.

Ultrasonography was performed on 10 patients with acute posttraumatic conditions of the knee in which X-ray films could exclude the presence of fractures. In 2 of 10 cases, the sonographic picture was normal; in the remaining 8 patients, ultrasonography disclosed capsulo-ligamentous lesions of different degrees of severity that were confirmed by surgery in 5 of 8 cases. The main sonographic signs of articular traumas were abnormal widening of the joint space (7 cases), intra-articular hemorrhage (8 cases), rupture of the medial collateral ligament (4 cases), or irregularity of its structure (3 cases). Ultrasonography is proposed as an effective and simple first-line method for the study of knee joint traumas. It can be performed in all cases presenting with painful joint swelling without radiographical evidence of fractures.

Ultrasonography of the hand in rheumatoid arthritis.

High resolution ultrasonography of the hand and wrist was performed on 20 patients with definite or probable rheumatoid arthritis (ARA standard criteria) in its early stage. In all the patients, swelling of the soft tissues of the fingers corresponded to an enlargement of the joint capsule containing a hypoechoic exudate. The rheumatoid nodules appeared as fluid-filled rounded cavities with sharp borders. Rheumatoid tenosynovitis was observed in 18/20 patients. This corresponded to oval or spindle-shaped cavities with a hypoechoic (10/18 cases) or anechoic content (8/18 cases) and with the tendon ribbon inside. Rupture of a tendon was diagnosed in 8/20 cases and it was always confirmed at surgery. Tenosynovitis of the flexor carpi ulnaris at the wrist level was observed in 10/20 patients. Ultrasonography is proposed as an effective first-line approach and as a periodical follow-up survey in early stage rheumatoid arthritis, in combination with standard radiography.

Detection of foreign bodies in soft tissues: experimental comparison of ultrasonography and xeroradiography.

The value of xeroradiography and of high-resolution ultrasonography was compared on minute samples of foreign bodies of various radiographic density (wood, plastic, metallic wires and needles, glass, fish bones). The samples were introduced into pieces of veal meat at different angles with respect to the surface. Xeroradiographic images were taken at 60 kVp, with 32 mAs, and were developed in both positive and negative mode. The echographic examinations were performed using a real-time sector 10 MHz probe placed directly over the specimen, with constant gain rates. The results confirm the value of xeroradiography and demonstrate the effectiveness of high-resolution ultrasonography for the detection of minute foreign bodies. Some materials showed a peculiar echographic pattern, like sand, that corresponded to a frank acoustic shadow, or like metal and glass, showing a comet tail of reverberation artifacts. Wood and fish bones were well outlined, while plastic was less effectively represented. High-resolution ultrasonography is considered to be a first-line technique in searching for many kinds of minute foreign bodies, to be used in combination with xeroradiography in routine clinical examination.

Ultrasonographic evaluation of Peyronie's disease.

High-resolution ultrasonography was performed on 58 patients with Peyronie's disease and on 6 healthy men; in 3 patients the examination was repeated during medical treatment for a follow-up period of 4 months. Peyronie's plaques always corresponded to abnormal echographic findings. In 54/58 cases (93%) they appeared as hyperechoic lesions. In 4 cases (7%) the plaques were hypoechoic and corresponded to a localized widening of the pericavernous tissues: this condition was observed more frequently in the earliest stages of the disease. There was good agreement between the palpable size of the plaques and their size measured by ultrasonography, with some degree of clinical overestimation of the smallest lesions. Calcified mature plaques corresponded to dense hyperechoic lesions with acoustical shadowing. High-resolution ultrasonography is proposed as a first-line diagnostic approach and as a reliable follow-up examination for Peyronie's disease. The possibility of differentiating calcified plaques from the more recent ones is helpful to allow a correct choice of medical or surgical treatment.

Digital angiography of erectile failure.

Digital angiography of pudendal and penile arteries was performed in 44 consecutive patients with erectile failure of suspected vascular origin. Intra-arterial injection of contrast medium via selective catheterisation of the hypogastric arteries was used in six cases. In 39 patients, one of whom had already had arterial catheterisation, contrast medium was administered by the intravenous route, using a single, large volume, high speed bolus. In 12/44 cases (27%), digital angiography showed a normal vascular picture at the pudendal and penile level but the remaining 32 patients (73%) had steno-occlusive lesions of different degrees of severity. The pictures obtained after administration of intravenous contrast were diagnostically as good as the studies with selective arterial catheterisation. In addition, the intravenous route allowed the simultaneous representation of the arterial network on both sides and was quicker and less invasive. In 31/44 patients (79%), functional determinations of nocturnal penile tumescence and of penile blood flow with Doppler ultrasonography were performed for comparison. Nocturnal penile tumescence results correlated well with the angiographic picture. Penile blood flow measurements with the Doppler technique were less sensitive than digital angiography.

High-resolution ultrasonography of wrist ganglia.

High-resolution ultrasonography was performed on 14 patients with soft tissue swelling of the wrist and hand. The examination was done using a real-time 10-MHz sector probe placed directly on the lesion. The sonographic image could always demonstrate the liquid nature of cystic lesions. In recent ganglia, the fluid content was anechoic, and the cystic walls were rather thin; in some older lesions, irregular internal echoes and thicker walls were found. Rather often, multiple ganglia were observed, grouped in clusters. The presence of a liquid-filled duct directed to the articular space was demonstrated in 8/11 cases (73%). This finding is considered a diagnostic characteristic of ganglia, and it is very useful for correct surgical planning. In extensor cystic tenosynovitis, the echographic picture was quite different: the anechoic cavity was longitudinal in shape, following the tendon sheath, and the communicating duct was absent. Finally, the sonographic pattern of one case of de Quervain's disease was analyzed and discussed.

The osteosarcoma amputation stump: a clinico-radiographical correlation.

The radiological picture of the amputation stump after osteosarcoma was reviewed in 75 cases, in which postoperative follow-up ranged from a minimum four months, to a maximum of over 12 years. In 67/75 cases (89%) no recurrence was observed; in 8/75 cases (11%) a local neoplastic recurrency was confirmed on clinical and histopathological grounds. The usual aspects of late modifications induced by surgery include osteoporosis of the residual bone, which may assume a geographical pattern, with thinning of the stump apex and formation of a periosteal spur directed towards the soft tissues. The typical pattern of locally recurrent osteosarcoma is that of an infiltrating soft tissue mass with bone erosion and irregular flake-like calcifications. All these signs are presented and discussed in order to give a practical guideline to the differential diagnosis between surgery-induced modifications and local neoplastic recurrences.

[Postoperative intravenous digital angiography of the carotid]. / L'angiografia digitale endovenosa della carotide operata.

Intravenous digital angiography was performed in 55 patients previously submitted to carotid endarterectomy. The angiographic examination was performed in asymptomatic subjects in 43/55 cases, as a routine procedure. In 12/55 cases (22%) the examination was performed following an ischemic recurrency. In 27 patients (49%), digital angiography was repeated before and after surgery, giving the opportunity of a serial evaluation of the vascular pattern. The angiographic findings in the site of operation was normal in 49/55 patients; in 6 patients (12%) steno-occlusive recurrencies were observed. In 21/55 cases (38%) carotid stenosis on the opposite side was demonstrated, owing to the pan-angiographic effect of intravenous contrast administration: among these cases, 18 appeared angiographically normal at the operation site. The clinico-angiographical correlation resulted fairly good (41/55-75%), taking into account the fraction of patients with contralateral carotid stenosis and neurological symptoms. Intravenous digital angiography is proposed as a first-choice diagnostic procedure for the follow-up after carotid surgery.

[Peripheral stenosing-occlusive arteriopathies. Doppler echographic and digital angiographic evaluation]. / Arteriopatie steno-occlusive periferiche. Valutazione ecografica Doppler e angiografia digitale.

The value of Doppler ultrasound examination and digital intravenous angiography was comparatively evaluated in 207 patients with peripheral vascular disease submitted to both techniques. Owing to the fact that in some patients more than one vascular district was examined, the overall number of evaluations was 232 Doppler ultrasounds and 233 digital angiographies. Doppler ultrasound revealed a normal picture in 18/232 cases, steno-occlusive disease in 186/232 cases and various pathological conditions in the remaining 18 cases. With digital angiography, normal vascularity was observed in 33/233 patients, while steno-occlusive disease was present in 164/233 and vascular anatomical abnormalities, like kinking, were found in 20 cases. Doppler/angiographical correlation was fairly good, being complete in 83/207 patients and substantial (i.e.: the same diagnosis but different degree of pathological involvement) in 79 additional cases: the overall diagnostic agreement between Doppler and angiography was 162/207 cases (78%). False negative Doppler results were 29/207, while the false positive Doppler examinations were 16/207. The most common causes of diagnostic errors are evaluated and discussed, both for Doppler ultrasound and for digital angiography. Arterial kinking and vascular abnormalities are recognized as an obvious cause of wrong Doppler diagnoses which can be easily discovered by the angiographic picture. The usefulness of performing both techniques in combination is demonstrated and stressed.

[Intravenous digital angiography of pulmonary circulation]. / L'angiografia digitale endovenosa del circolo polmonare.

Intravenous digital angiography was performed in 92 patients with pulmonary diseases. The examination yielded satisfactory results in 82/92 cases (89%). The most promising fields of application of pulmonary digital angiography are: vascular malformations (3 cases: 3%), pulmonary emphysema (24 cases: 26%) and pulmonary embolism (38 cases: 41%). In tumoral masses (14 cases: 15%) digital angiography showed dislocation of the surrounding pulmonary vessels but failed to demonstrate the intrinsic vascularity of the mass, deriving from the bronchial arteries. In post-lobectomy controls (10 cases: 11%) the examination gave a good demonstration of the absence of vascular supply at the site of the previous surgery. Intravenous digital angiography shows many technical limitations, namely a reduced resolution power and a small field of view; in addition, it requires patient immobility, which results sometimes impossible in critically ill patients. In spite of these inconvenients, however, intravenous digital angiography appears to be an important diagnostic step for the evaluation of pulmonary embolism and vascular malformations: in these conditions, digital angiography can be the procedure of choice.

Surgical or radiosurgical failures on cervical lymph nodes in treatment of head and neck cancer.

From a series of 850 patients with head and neck carcinoma and subjected to lymph node dissection, 80 cases of recurrences in the neck have been collected. Postoperative radiotherapy was performed only in cases with metastatic extranodal spread. Of these recurrences, 56 occurred in the area of lymph node dissection, 7 were marginal and 17 were contralateral. The recurrences occurred prevalently in node-positive (N+) patients (70 of 80). The incidence of recurrences in the dissection area was 41.6% (25 of 60) in cases with metastatic extranodal spread, despite postoperative radiotherapy. The incidence of recurrences in cases with clinically evident metastases at the time of dissection but without extranodal spread and not subjected to postoperative radiotherapy was relatively high (24.1%, or 28 of 116). Since recurrences occurred, despite postoperative radiotherapy, in a relatively high percentage of cases with carcinoma of the oral floor and of the tongue (59.1% and 50%, respectively), it seems justifiable to perform preoperative radiation treatment in cases with clinically evident metastatic lymph nodes. As regards marginal recurrences, which all occurred in patients with carcinoma of the oral floor, it is considered sufficient to extend the surgical treatment to the subhyoid region. The high incidence of contralateral recurrences, which occurred mainly in patients with carcinoma of the larynx (13 of 17), shows the usefulness of radiation treatment of the contralateral region of the neck in these tumors, when dissection is limited to only one side of the neck.