Growing indications for CEUS: The kidney, testis, lymph nodes, thyroid, prostate, and small bowel.

Contrast enhanced ultrasonography (CEUS) is increasingly used for non-hepatic applications as well, so that nearly all organs have been investigated. Among them, there is a growing clinical use for a variety of pathologies of the kidney, testis, and small bowel. The possibility to differentiate benign from malignant nodes in cancer patients has been investigated. A new application is in the detection of sentinel nodes after intradermal microbubble injection. The need to distinguish thyroid nodules eligible for fine needle aspiration cytology has led to the use of CEUS in thyroid examinations as well. The potential of CEUS for prostate cancer detection has been extensively investigated, with encouraging initial results. Early promise, however, has not been fulfilled. New perspective regards evaluation of the extent of prostate tissue devascularization following ablative treatments.

Thoracolumbar fractures without neurosurgical involvement: surgical or conservative treatment?

The decision whether to treat amyelic thoracolumbar fractures conservatively or by surgical approach depends mainly on radiographic and clinical evaluation of their potential stability. An angle of kyphosis of 20 degrees or more evaluated using the sagittal index (s.i.) described by Farcy et al. in 1990, may be a valid indication for invasine treatment using pedicular systems for correction and stabilization; on the other hand, conservative treatment may be adequate for ensuring satisfactory results in fractures with an angle of less than 20 degrees, which are less likely to become unstable in clinically negative patients. This study confronts the immediate and long-term radiographic and clinical results in 2 groups of patients treated for amyelic thoracolumbar fractures, one treated conservatively, the other surgically; in particular, angle of kyphosis, vertebral compression and clinical conditions (pain and functional impairment) at long-term follow-up were assessed. The study was extended to include an assessment of outcome in relation to the angle of post-traumatic kyphosis in both operated and non-operated patients. Thirty-one patients with a diagnosis of non-neurological thoracolumbar trauma of the segment between D11 and L3 were studied. Twenty patients (group A) were treated conservatively (reduction on Cotrel bed and plaster vest) and 11 (group B) surgically (Diapason instrumentation). The 31 patients were subdivided into 2 groups according to the initial angle of kyphosis calculated using the s.i.: the first consisted of 16 patients (group C) with a s.i. of 20 degrees or more and the other of 15 patients (group D) with a s.i. less than 20 degrees. Six of the 16 group C patients and 5 of the 15 group D patients had been surgically treated. On the basis of the case-material considered, we found that satisfactory short-term radiographic results may be obtained by both conservative and surgical treatment. However, long-term outcome is less favorable in patients treated conservatively because maintainance of the initial improvement of the deformity in the injured segment is not as good as in those treated surgically. This limitation of conservative treatment does not however appear to negatively influence clinical conditions in patients with a s.i. of less than 20 degrees. In other words, although conservative treatment is not as effective as surgery for maintaining radiographic improvement, this does not necessarily signify clinical deterioration in cases with a s.i. of less than 20 degrees in whom the two types of treatment gave similar results.

Impact of gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance on the non-invasive diagnosis of small hepatocellular carcinoma: a prospective study.

BACKGROUND: Gadoxetic acid (Gd-EOB-DTPA) is a 'hepatocyte-specific' contrast agent for magnetic resonance (MR) in both the vascular and the hepatobiliary phases. AIM: To evaluate the contribution of the hepatobiliary phase of Gd-EOB-DTPA MR in the diagnosis of small hepatocellular carcinoma (HCC) in cirrhotic patients under surveillance. METHODS: Between 2008 and 2011, 48 consecutive small (10-30 mm) liver nodules were detected in 33 patients, who prospectively underwent contrast-enhanced ultrasound (CEUS), Gd-EOB-DTPA-enhanced MR and helical-computed tomography (CT) in a blind study. The diagnosis of HCC was established according to AASLD 2005 criteria. RESULTS: Of the 48 nodules, 38 (79%) were diagnosed as HCC, 24 (63%) of them based on AASLD non-invasive criteria, 11 diagnosed at histology and 3 during follow-up. The typical vascular pattern (arterial hypervascularisation and venous/late washout) was detected in 30 (79%) HCC nodules by MR, in 22 (58%) by CT and in 17 (45%) by CEUS. Hypointensity during the MR hepatobiliary phase was observed in all HCC nodules and in 3 nonmalignant nodules (sensitivity 100%, specificity 70%, positive predictive value 93%, negative predictive value 100%, positive likelihood ratio 3.33, negative likelihood ratio 0). Eight (21%) of the 38 HCC nodules, 7 of which lacked the typical vascular features at any of the imaging modalities, showed washout in the portal/venous phase and hypointensity in the hepatobiliary phase at MRI, while this pattern was not detected in any nonmalignant lesion. CONCLUSIONS: Gadoxetic acid magnetic resonance may enhance the sensitivity of the non-invasive diagnosis of small hepatocellular carcinoma nodules in cirrhotic patients under surveillance. Double hypointensity in the portal/venous and hepatobiliary phases could be considered a new magnetic resonance pattern, highly suggestive of hypovascular hepatocellular carcinoma.

Acoustic Radiation Force Impulse (ARFI) ultrasound imaging of solid focal liver lesions.

OBJECTIVE: The aim of this paper was to evaluate the application of ARFI ultrasound imaging and its potential value for characterizing focal solid liver lesions. MATERIALS AND METHODS: In this multicentric prospective study, over a total non-consecutive period of four months, all patients underwent ARFI US examination. Two independent operators performed 5 measurements per each lesion and 2 measurements in the surrounding liver. According to the definitive diagnosis, a mean velocity value and standard deviations were obtained in each type of focal solid lesion, compared by using t-test, and the inter-operator evaluation was performed by using the Student's t-test. A comparison between the total mean values of each type of lesion and the mean value of the parenchyma was performed. RESULTS: 40 lesions were evaluated and a total of 400 measurements were obtained. The lesions were: 6/40(15%) hepatocellular carcinomas, 7/40(17.5%) hemangiomas, 5/40(12.5%) adenomas, 9/40(22.5%) metastases and 13/40(32.5%) focal nodular hyperplasias. The total mean values obtained were: 2.17 m/s in HCCs, 2.30 m/s in hemangiomas, 1.25 m/s in adenomas, 2.87 m/s in metastases and 2.75 m/s in FNHs. The inter-operator evaluation resulted non-statistically different (p>0.05). A significant difference (p<0.05) was always found by comparing adenomas to the other lesions. 160 measurements were obtained in the surrounding parenchyma, with a no significant difference between values measured in adenomas and in the surrounding liver. CONCLUSIONS: ARFI technology with Virtual Touch tissue quantification could non-invasively provide significant complementary information regarding the tissue stiffness, useful for the differential diagnosis of focal solid liver lesions.

Synovial ganglia of the central pivot of the knee.

Five patients with intraarticular synovial ganglia of the knee were treated by arthroscopic surgery. These synovial cysts were found in the intercondylar fossa and appeared to originate from the cruciate ligaments. In 3 patients the ganglia were the only pathologic finding, solely responsible for the pain and functional impairment. In the other 2 patients the ganglia were accompanied by other intraarticular lesions. The diagnostic procedure (radiography, arthrography, CT, MRI, arthroscopy), confirmed the validity of CT scan and MRI in detection, differential diagnosis, and location of the ganglia in all cases. Arthroscopy enabled us to directly observe, biopsy, and remove the ganglia, resulting in immediate disappearance of symptoms and no relapse after a minimum follow-up of 20 months.

Grice's operation for spastic flat foot.

The authors report 24 cases of severe spastic pes valgus in children affected by cerebral palsy, treated surgically by a technique derived from that of Grice - taking the transplant from the calcaneus itself instead of from the usual sites. They discuss the parameters usually considered in assessing the results and describe their own method of interpreting the measurements derived from the angles usually employed in the evaluation of pes valgus.

A mould arthroplasty revision: a 43-year follow-up.

We present the outcome of a mould arthroplasty implanted for a congenital hip dysplasia in 1955 to revise a previous cup arthroplasty. This type of prosthesis, which has been developed on the basis of the concept of Smith-Peterson, by Prof. Marino-Zuco in Rome in the early 1940s, showed excellent results and was widely used until the advent of Charnley low-friction arthroplasty.

Cystic degeneration of the external meniscus. Part 2: Arthroscopic meniscectomy.

A consecutive series of 12 patients with cystic degeneration of the external meniscus was treated by selective external meniscectomy with an arthroscopic approach associated with percutaneous decompression of the cystic formation. Selective meniscectomy, on the one hand, allows for the preservation of a vast meniscal surface, thus preserving its functions as a shock-absorber, and on the other, in association with percutaneous decompression, it minimizes the possibility of recurrence. The authors discuss the procedures and advantages of this surgical method, which produced excellent immediate results due to the minimal trauma related to the use of arthroscopy, as well as the medium- and long-term results.

Cystic degeneration of the lateral meniscus. Pathogenesis and diagnostic approach.

Twelve patients with cystic degeneration of the lateral meniscus were submitted to magnetic resonance and arthroscopy. This study showed that mixoid degeneration is produced initially within the meniscal substance and subsequently progresses towards and may rupture through the outer margin, so producing the clinically detectable cyst on the outer margin of the joint. In the light of the information obtained from magnetic resonance and subsequent surgical verification, existing hypotheses regarding the pathogenesis and evolution of the lesion have been re-examined.

Arthroscopy in the treatment of osteochondrosis dissecans of the talus.

This study consists of six cases of osteochondrosis dissecans of the talus (ODT) treated with arthroscopy, which was able to precisely evaluate the integrity of the articular surface; this exact evaluation confirmed in turn the inaccuracy of radiographic staging and often even the most sophisticated techniques (CAT scan and/or MRI). Arthroscopy allows treatment of osteochondral lesions and consensual reactive synovitis in both advanced stages and minor lesions, with recourse to transchondral perforation. Its low morbidity and short period of rehabilitation together with the subjective and objective outcome at the follow-up (4-33 months) make arthroscopy a valid alternative to arthrotomy for treating this type of lesion.

Histological and morphological aspects of muscle in infantile cerebral palsy.

There is very little in the literature on the histology and morphology of muscle in cerebral palsy. The authors studied the histology of antigravitational spastic muscles, which are different from the nonspastic muscles. The study established that they have no endomysial fibres and that their inelasticity and inextensibility is due to syncytial atrophy. This is in conformity with clinical findings and calls for further research into the ultrastructural nature of the muscle so that treatment can be based on a more complete understanding of the disease and not solely on clinical observations.

Current trends in conservative treatment of fractures of the proximal humerus.

Forty-nine fractures treated conservatively with 30 days of immobilization in a Desault bandage or a suspension cast (3 cases) are discussed. The diaphyseal index was used to check for correlation between the degree of osteoporosis and the extent and type of fracture. After an average follow-up of 6.7 months, 67% of the 36 patients reviewed had a satisfactory clinical and radiographic result and adequate healing, even those with a high degree of osteoporosis. There was no significant correlation between the type of fracture (location and degree of displacement) and the severity of bone resorption. We would emphasize that 33% of the unsatisfactory results were mostly due to the radiographic findings which, scored using the Neer system, were rated unsatisfactory even though the corresponding results were satisfactory as far as the clinical symptoms and signs. In our opinion, proximal humeral fractures in elderly patients should be treated conservatively, especially in cases of slight or moderate displacement.

EEG and clinical features in epileptic children during halothane anaesthesia.

Clinical and EEG changes were studied in 12 children affected by infantile cerebral palsy and generalized or focal epilepsy, during and after halothane anaesthesia induced by orthopaedic surgery. The anaesthesia was induced by inhalation of halothane 1.5%, and maintained with halothane 0.5%. During anaesthesia a decrease of the incidence of epileptic abnormalities was observed in 10 patients. In the other 2 children no changes were seen. At the end of surgery, when the anaesthetic was gradually suspended, there was a notable increase of epileptic abnormalities in 4 children. Clinical seizures were never observed during or shortly after surgery. In the majority of the cases, the EEGs performed 1 week later did not show modifications of epileptic abnormalities, as compared to the preoperative EEGs. Only in a few patients the epileptic activity was modified. The data show that halothane anaesthesia can be used in epileptic children without risking activation of seizures.

Patellofemoral dysplasia in infantile cerebral palsy.

The authors have studied the biomechanical basis of functional alterations in the extensor apparatus of the knee in cases of infantile cerebral palsy. Several interesting aspects of the problem, some of which are controversial, have emerged from this study and from a review of patients with flexion contracture of the knee treated surgically: 1. The neurological pathology of the motor system leads to problems of posture and dysplastic conditions of the hip (coxa valgus, etc.) which favour the development of patellofemoral pathology. 2. By contrast, the early clinical manifestations of this pathology are relatively insignificant and completely overshadowed by the major problems of adaptation and compensation imposed by the more serious overall disabilities which face the patient in order to stand and walk. The knee plays a prevalently static role at this stage and is not particularly stressed during joint movement. 3. The clinical manifestations of patellofemoral pathology are thus paradoxically brought into focus by surgery on the flexor apparatus to deal with contracture. Although on the one hand this improves function, on the other it brings to light the more complex functional mechanisms of the knee, thus emphasizing any deficit in the extensor apparatus.